Voices of the Poor_

							Voices of the Poor:
Making Services Work for the Poor in Indonesia

Nilanjana Mukherjee

INDOPOV

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This paper has not undergone the review accorded to official World Bank publications. The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the International Bank for Reconstruction and Development / The World Bank and its affiliated organizations, or those of the Executive Directors of The World Bank or the governments they represent.

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Voices of the Poor:
Making Services Work for the Poor in Indonesia
A Qualitative Consultation with the Poor at Eight Sites
Nilanjana Mukherjee

Bank Dunia | The World Bank East Asia and Pacific Region

Acknowledgements
Voices of the Poor is based upon field work done by a team consisting of Nyoman Oka and Ratna Indrawati Josodipoero, Co-field team leaders, Wiji J. Santoso, Idul Fitriatun, Ketut Suarken, and Nur Khamid (East Java Team), Purnama Sidi, Laksmini Sita, Herry Septiadi, and Ririn Fajri (West Java Team), Husnuzzoni, Khusairi, Nazmi Rahkman, and Indraningsih (South Kalimantan Team), Titik Soeprijati, Irwan, Mochamad Rifai, and Ariati (West Nusa Tenggara Team).

Field work and analysis for Voices of the Poor was supported by the Indonesia Poverty Analysis Program (INDOPOV), a partnership program of the World Bank Indonesia led by Jehan Arulpragasam. The report is a qualitative study intended to supplement the quantitative analysis “Making Services Work for the Poor in Indonesia.”

This work benefited from advice, discussion, and critique from members of the INDOPOV team, particularly Menno Pradhan, Vicente Paqueo, Peter Heywood, and Ellen Tan. Suzanne Charles and Ellen Tan provided valuable editing support. Claudia Surjadjaja provided health service assessment tools and briefing to the researchers. Consultations with the poor were undertaken by the researchers drawn from several NGOs and academic institutions in Indonesia.

Grateful thanks are due to the women and men consulted in the Java, Kalimantan, and West Nusa Tenggara communities, who shared their assessments, experiences, insights, and knowledge to provide a human face and voice to this study – which we hope will be heard by policy makers.

The author deeply appreciates the support of the management of the World Bank’s Water and Sanitation Program (WSP), which made it possible for her to undertake this work. Specifically, thanks are due to Richard Pollard, the Regional Team Leader for WSP - East Asia and Pacific, and Ede Jorge Ijjasz-Vasquez, the global Program Manager.

For any shortcomings and omissions in this report, the author claims responsibility

Table of Contents
ACKNOWLEDGEMENTS TABLE OF CONTENTS LIST OF BOXES, FIGURES, & TABLES GLOSSARY EXECUTIVE SUMMARY 1. POVERTY CHARACTERISTICS AND LOCAL INSTITUTIONS AT STUDY SITES
1. 1. Sample, Sites, Research Tools 1. 2. Identifying And Engaging With The Poor 1. 3. Local Well Being And Poverty Profiles

iv v vi viii 1 1 2 2 4 4 6 8 9 14 14 16 17 18 21 25 25 26 27 29 30 31 33 34 35 36 38 39 39 40 42 42 43 44 45 Voices Of The Poor
v

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2. EDUCATION SERVICES USED BY THE POOR
2. 1. Primary Schools: Not Really Free – Despite Government Provisions 2. 2. Secondary School Education Services 2. 3. Quality Of Services - Providers’ Views 2. 4. Independent Observation Results And Conclusions

3. HEALTH CARE: PRENATAL, CHILDBIRTH, AND CHILD HEALTH SERVICES
3. 1. Prenatal Services: Preferences Vary With Geography 3. 2. Childbirth Assistance Services: Tba Still Reigns Supreme 3. 3. Curative Services For Young Children (< 5 Years): Public Services Are The Preferred Choice 3. 4. Quality Of Health Services Being Delivered To The Poor 3. 5. Independent Observation Results And Conclusions

4. “CLEAN” WATER SERVICES USED BY THE POOR
4. 1. Poor Lack Reasonable Access To Potable Water 4. 2. Water Use And Health Hazards 4. 3. The Poorest Pay The Highest Price For Water 4. 4. Observation Results: “Clean” Water Services 4. 5. Quality Of Services: Views Of The Poor

5. SANITATION FACILITIES USED BY THE POOR
5. 1. Observation Results: Sanitation Services 5. 2. Quality Of Services: Various Views

6. POOR HAVE LITTLE CLIENT POWER—BUT THEY WANT IT
6. 1. Lack Of Information-“We Don’t Know” 6. 2. “Who Will Hear Us?” 6. 3. Poor Treatment By Pro-poor Service Providers And Officials 6. 4. No Voice In Community Decisions And Service Provision 6. 5. Problems With The Participatory Process-“We Are Stepchildren”

7. RECOMMENDATIONS FOR POLICY AND STRATEGY
7. 1. For Basic Services In General 7. 2. For Health Services 7. 3. For Education Services 7. 4. For Clean Water And Sanitation Services

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

List of Boxes
Box 1. No explanation of fees Box 2. Married at 13, childbirth at 14 –the only option after primary school Box 3. No clean water equals no schoolteachers and health workers Box 4. 92 Enrolled but 29 Present Voices Of The Poor Box 5. Pregnancy danger signs unrecognized Box 6. Repeated premature births, No ANC check ups Box 7. No longer possessed by the devil Box 8. Four days too late … Box 9. How to feed my child when breast milk fails? Box 10. Diarrheal death of an infant close to services in a mega city Box 11. The poor pay 30 times PDAM tariff for water – but don’t realize it Box 12. Held ransom by monopolistic water service Box 13. “They give us no choice….” Box 14. “Because i am poor, and therefore also stupid ” Box 15. Kartu sehat users need patience and forbearance 6 7 10 10 17 22 23 23 24 25 27 30 36 38 39

List of Figures
Figure 1. Proportion of votes for choice of provider for primary education services Figure 2. Proportion of votes for choice of provider for ANC services Figure 3. Proportion of votes for choice of water services used Figure 4. Proportion of votes for choice of sanitation facility used 6 15 26 32

List of Tables
Table 1. Study sites Table 2. Secondary school observations at different sites Table 3. Costs of clean water services and water use by the poor at 8 study sites 1 13 28

List of Annex Tables
Table 2.1. Paminggir - Remote, Forestry-dependent Rural Community, South Kalimantan Table 2.2. Bajo Pulau - Island Fishing Community , West Nusa Tenggara Table 2.3. Alas Kokon - Rural, Dryland Farming Community, Madura, East Java Table 2.4. Kertajaya – Irrigated Rice-Farming Rural Community, West Java Table 2.5. Antasari - Urban Kelurahan, South Kalimantan Table 2.6. Jatibaru - Urban Poor Kelurahan on the Outskirts of Bima, West Nusa Tenggara Table 2.7. Simokerto - Urban Low-Income Neighborhood and Squatters’ Settlement, Surabaya, East Java 5 5 6 7 8 9 10

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Table 2.8. Soklat - Urban Poor Kelurahan in Subang, West Java Table 3.1. Choice and Costs of Primary Education Services Reported by the Poor at 8 Sites Table 3.2. Costs of secondary school education reported by the poor at 8 study sites Table 3.3. Choice and Costs of ANC Services Used by the Poor at 8 Study Sites Table 3.4. Cost of Childbirth Assistance Services Used by the Poor at 8 Study Sites Table 3.5. Costs of One-time Use of Curative Care Services Most Used by the Poor for Their Children under Five

11 12 15 19 22 26 Voices Of The Poor
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List of Annex Figures
Figure 3.1 Benefit and value perceptions for primary education services Figure 3.2 Satisfaction Ratings for Primary Education Providers Figure 3.3 Proportion of votes for provider of secondary school education services Figure 3.4 Benefit and value perceptions for secondary school education services Figure 3.5 Satisfaction ratings for secondary school education providers Figure 3.6 Benefit and Value Perceptions for ANC Service Providers Figure 3.7 Proportion of votes for choice of provider for Childbirth Assistance Services Figure 3.8 Satisfaction Ratings for Childbirth Assistance Providers Figure 3.9 Benefit and Value Perceptions for Childbirth Assistance Providers Figure 3.10 Proportion of votes for provider of Infant Health Care Services (2M – 5Y) Figure 3.11 Proportion of votes for provider of Infant Health Care Services (0 - 2M) Figure 3.12 Benefit and Value Perceptions for Curative Services for Infants (0-2 months) Figure 3.13 Satisfaction Ratings for Curative Care Providers for Infants (0-2 months) Figure 3.14 Benefit and Value Perceptions for Water Supply Option Used Figure 3.15 Satisfaction ratings for water supply options Figure 3.16 Benefit and value perceptions for sanitation facilities Figure 3.17 Satisfaction ratings for sanitation facilities 13 14 16 17 18 20 21 23 24 25 25 27 28 29 30 31 32

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Glossary
ANC Arisan bidan desa BKKBN (Badan Koordinasi Keluarga Antenatal Care Saving & Credit Group Trained Village Midwife National Family Planning Coordinating Board

Voices Of The Poor

Berencana Nasional) BOS (Biaya Operasional Sekolah) BPS (Badan Pusat Statistik) Dukun Dusun GDS GOI Imunisasi TT (Tetanus Toxoid) Inpres Desa Tertinggal Kangkung Kantor Kelurahan Kapuk Kartu Sehat Kec./ Kecamatan Kelurahan Kelurahan /Kantor Desa Kepala Desa Kepala Dusun Ketua RT Madrasah Madrasah Ibtidaiyah Madrasah Tsanawiyah School Operation Costs Central Bureau of Statistics Local faith healer Hamlet Governance and Decentralization Survey Government of Indonesia TT (Tetanus Toxoid) immunization Presidential program for disadvantaged villages Leafy vegetable Political District Office Silk Cotton Health Card Sub-district Sections of the village/Urban district admistration unit Political District Office administered by Lurah (Village Chief ) Village Chief Hamlet Chief Neighborhood Community Head Religious School, privately managed Community-managed Islamic Schools (grades 1-6) Religious school, run by government (Department of Religious Affairs), grades 6 – 8) Mantri Menengah MOE NGO PDAM (Perusahaan Daerah Air Minum) Pesantren PKK PLN Polindes (Poliklinik Desa) POSYANDU (Pos Pelayanan Terpadu) Puskesmas Pustu (Puskesmas pembantu) Raskin (Beras Miskin) Other Islamic Schools Women’s Family Welfare Program State Electricity Corporation Village Birthing Clinic Integrated Services Post Primary Health Centre/ Sub-district Public Health Centre Sub-primary Health Centre (outreach facility) Cheap Rice Paramedic Middle/Sufficient Ministry of Education Non Governmental Organization Regional Drinking Water Company

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

SANIMAS

Community Sanitation Project piloted in 7 Indonesian cities during 2001-2003, promoting community-based sanitation solutions for the urban poor

SD (Sekolah Dasar) SDN (Sekolah Dasar Negeri) SLTP (Sekolah Lanjutan Tingkat Pertama)/ SMP (Sekolah Menengah Pertama) SLTP Negeri/ SMP Negeri SSIP TBA

Primary School (grades 1 – 6) Government – run Primary School (grades 1 – 6) Junior High School or Secondary School, generally grades 7-9

Government – run Junior High School Small Scale Independent Water Providers Traditional Birth Attendant (Sando, Dukun Beranak/ Dukun Berobat, Dukun/Bidan Kampung, Paraji)

UKS (Unit Kesehatan Sekolah)

School Health Education Unit

*At the time of the study, 1 US dollar was equal to 9700 Indonesian Rupiah.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

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Voices Of The Poor

Executive Summary
In January 2001, Indonesia decentralized the delivery of most government services to the district level. The center of gravity for innovation has thus shifted to the districts, where local governments now have significant autonomy to promote change, both positive and negative. In a country of about 2201 million people and 4402 districts and cities, Voices Of The Poor this shift has created tremendous potential for innovative local approaches for public sector service delivery.

The World Bank’s Making Services Work for the Poor in Indonesia initiative aims to provide analytical support for the Indonesian Government’s efforts to improve access to and quality of basic services for the poor in the wake of decentralization. Its objectives are to summarize the state of basic service delivery for the poor, identify and analyze key factors that have an impact on current outcomes, and propose an analytical framework and practical steps for improving pro-poor service provision.3

None of the fairly extensive literature on decentralization has yet included an analysis of how the poor view the delivery of public services. This report attempts to fill this gap. It tries to understand what constraints the poor face, and the rationale for choices made by the rural and urban poor with respect to basic health, education, water supply and sanitation services that they need. The report also describes policy recommendations to improve service delivery for the poor on the basis of this analysis, and suggestions from the poor and service providers that could help improve accountability and strengthen relationships among clients, service providers, and policy makers.

This study focused on eight types of key services:4 • • • • • • • • antenatal services childbirth assistance curative services for 0 to 2 month old infants curative services for >2 months to 5 year old children primary schooling transition to secondary schooling clean water services sanitation facilities (excreta disposal)

These services are important elements in reaching the Millennium Development Goals. High malnutrition, maternal and infant mortality, and low education can be directly traced back to failings in these services.

1 2 3 4

National Bureau of Statistics BPS, “Proyeksi Penduduk Indonesia, 2000-2005”, 2005 Ministry of Home Affairs For the full report, see the World Bank website, www.worldbank.or.id For the purposes of this report, curative services have been combined. For specific results of 0 to 2 months and > 2 months to 5 years. Please see Annex.

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

It is hoped that this synthesis, which pulls together commonalities and differences among eight localities, will be useful to donors and government in Indonesia, as well as other countries interested in practical ideas for improving government service delivery.

By participating in the delivery of services and pressuring policy makers and service providers, the poor have the potential to improve the quality of services they receive. The study explored to what extent the poor do this and whether they deem their efforts to be effective. The study also sought their views on how they can draw policymakers’ attention towards the aspirations of the poor and how to improve the accountability of the service providers to serve poor consumers. Voices Of The Poor
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Generally, the policy response in Indonesia to lack of utilization of basic services by the poor, or disappointing service outcomes, has been to use targeted price subsidies for public service provision, such as the health card and scholarships programs. These policies presume that the public sector is the most efficient way to deliver services to the poor and that the poor do not use them when the fees are too high. This study was designed to take a fresh look at this hypothesis, which has been driving policy in Indonesia, and to generate suggestions for alternative policies that are more directly related to the constraints the poor face.

The following findings represent the voices of the poor from eight selected locations in Indonesia. No claim is made about their being completely representative of the country’s poor.

A number of key messages reverberate throughout the consultations:

1. Perceptions of the poor on service quality were often at variance with independent professional views on quality. • The poor perceived traditional birth attendants (TBAs) to be providing better quality service for childbirth assistance than trained nurse midwives. • Well water is perceived as clean, whereas river water is not. While the latter is mostly correct, the first is often not.

2. The primary constraint to increasing the number of births assisted by trained service providers appears to be lack of demand rather than lack of access. The poor do not demand trained midwives’ services because midwives charge much more and serve their clients for much shorter periods than the TBAs do. Many poor clients were not fully aware of the additional benefits of professionally assisted births. Those who were aware were not certain the additional benefits are worth the high extra cost.

3. Programs for the poor, such as the health card, are highly valued, but researchers found that information about policies for the poor is typically not available. Often, the public service provider or government official was the sole source of information about pro-poor services. Often these elites failed to give the poor complete information, and sometimes they even misused their power, preventing the poor from accessing these services.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

4. Community elite—service providers and government officials— seldom listened to the poor when the poor were stating their needs, their concerns, or ideas they have for improvements to service. The poor see themselves as “stepchildren”; the elites consider the poor as “stupid” and do not want to interact with the poor or provide them with information. The only way input from the poor is valued is when it is mediated through outside partners. Voices Of The Poor

5. Non-fee primary school expenses (such as uniforms, books, etc.) are a substantial burden for the poor. The recent policy to abolish tuition fees for the poor does not address these significant non-fee expenses.

6. Public perceptions about the poor being unable to afford quality water and sanitation services are not correct. The poor in urban areas were buying water from private vendors at 15 to 30 times the tariffs of the district drinking water companies (Perusahaan Daerah Air Minum, PDAM). While they could afford to buy water from PDAMs at the PDAM tariff rates, they fail to obtain connections due to lack of tenure of lease or land ownership and the high one-time cash costs of connections. Most of the urban poor could afford to build low-cost latrines, but again lack of land ownership or tenure of residence stands in the way. Also, most are not aware of low-cost latrine options, both in rural and urban areas.

7. On islands, the poor have little access to clean water, often because of the monopolistic manipulation of the system by water vendors. This was also true in an urban slum.

8. There is a big difference in quality between urban providers serving slum areas and rural providers serving poor areas. The latter are of much worse quality.

9. Particularly in rural areas, many children enrolled in school do not attend regularly. Their teachers are often absent. High enrollment rates fail to capture non-attendance.

10. Teacher absenteeism in rural schools and the unavailability of paramedics in rural health outposts (Pustus) were sometimes tied to the lack of basic infrastructure facilities such as water supply and sanitation facilities in rural schools and health posts. Teachers were not willing to work in such conditions (although they were willing to be paid).

11. When there is no secondary school in the village, such as seen in Madura, girls were married off and get pregnant immediately after primary schooling. When there is a chance of attending junior high, such young marriages do not occur as frequently. This emphasizes the need to improve girls’ access to junior high school for reasons beyond educational attainment.

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1.

Poverty Characteristics and Local Institutions at Study Sites

1. 1. Sample, Sites, Research Tools
Voices Of The Poor
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Eight localities were chosen based on BKKBN poverty criteria, inclusion in the Governance and Decentralization Survey, Badan Pusat Statistik’s poverty maps and geography/locality. Communities chosen, both rural and urban, had high poverty rates (30 to 80 percent). Social mapping was further used at each site to identify the poorest neighborhoods for consultation. Half of the sites were chosen on Java, which houses the largest absolute number of the country’s poor. Two other sites, West Nusa Tenggara and Kalimantan, were included to reflect conditions outside Java. The 2003 GDS results had shown high satisfaction rates with public services and popular perceptions of improved services after decentralization. The quantitative GDS results neither explained why ratings were high, nor whether the views of the poor differed from that of the non-poor. Poor people’s views about services in this study were far less positive than the GDS results, possibly reflecting the experience of the poorest segments.

Criteria for selection of rural sites included principal livelihoods (irrigated rice-growing farmers in West Java, an island fishing community in West Nusa Tenggara, a forestry-dependent upland agricultural community in South Kalimantan, and a dry land agricultural community in Madura (see Table 1).

Table 1. Study Sites JAVA Rural livelihoods Urban community Rural Forestry and upland agriculture livelihoods Irrigated agriculture-based Mega city slum OFF-JAVA Urban Small town community

Desa Kertajaya, District Subang, West Java

Kelurahan Simokerto, Kecamatan Simokerto,

Desa Paminggir, Kecamatan Danau

Kelurahan Antasari, Kecamatan Amuntai Tenggah, South Kalimantan Small town community

District Surabaya, East Java Panggang, District Hulu Sungai Utara, South Kalimantan Dry land agricultural livelihoods Urban poor community Coastal fishing community

Desa Alaskokon, Kecamatan Modung, District Bangkalan, Madura

Kelurahan Soklat, Kecamatan/Kota Subang, West Java

Desa Bajopulau, District Sape, West Nusa Tenggara

Kelurahan Jatibaru, Bima City, West Nusa Tenggara

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Research methods included the use of participatory analysis tools and focus group discussions with poor men and women, and in-depth interviews with individuals selected for case studies. A total of 450 people were consulted. The views of four subdistrict health center doctors, six village midwives (bidan desa), two paramedics, four traditional birth attendants, seven primary school teachers, and three secondary school teachers were incorporated into findings. Observations with service quality standard checklists were carried out at 16 primary school classes, eight secondary school classes, homes of four TBAs and two bidan desas, six subdistrict health centers and two sub centers. Voices Of The Poor Water filling and supply facilities were observed for two Small Scale Independent Water Providers (SSIPs); 16 school sanitation facilities and 23 household sanitation facilities were observed. Teams spent a total of 42 person-days in the field between October and November 2005.

1. 2. Identifying and Engaging with the Poor
It is easy to miss the real poor while carrying out community level consultations or research. The poor, who are at the bottom of the social ladder, rarely attend community meetings. They cannot afford to take time off from work and often they are not invited to meetings. From past experience, the poor have no reason to trust outsiders and talk freely about their experiences, which are often very different from the glossed-over versions repeated by formal leaders. Researchers were equipped with a sequence of participatory analysis and qualitative research tools (described in Annex 1, pg. 1-4) designed to address the communication barriers described above and gather views, assessments and experiences of the poor.

Four research teams of four people each spent four to five days in each community. Each team had two men and women from NGOs or academia who held sessions with men and women’s groups. They explained the purpose of the study, first to the formal leaders of the communities and then to the poor.

The interest at each site was high. No one had asked the poor about their views regarding basic services before. They were at first surprised, and then expressive in their assessments and explanations. As work progressed, visual analysis tools attracted participants and attendance grew. No incentives were offered for participation and none was needed. The group sessions resembled enjoyable social events which lasted late into the evening.

1. 3. Local Well Being and Poverty Profiles
For detailed information on sites and poverty, see Annex 2, pg. 5-12. It is particularly interesting to note differences in who is considered poor by local standards compared to official standards.

PAMINGGIR: Paminggir, a remote village of 333 households in kecamatan Danau Panggang, district Hulu Sunggai Utara in South Kalimantan, is classified as a “left behind village” by the GOI program Inpres Desa Tertinggal. Half of the households are poor, by local standards. Well-being is measured in terms of one’s control over means of livelihoods, i.e. boats, fishing equipment, fishponds, and buffaloes. The poor are defined, in contrast, by what they do not have.

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

The village is accessible only by boat, two to six hours away from the district capital. The community depends on the river for its livelihood, fishing, as well as transport. Land is swampy, unsuitable for crops. Rainfall is heavy and flooding is frequent. The community has one public primary school, a secondary school and a sub-health center open two to three days a week. The nearest bidan desa is six kilometers away, the nearest health center 14 kilometers and difficult to reach. The village has no clean water source or sanitation facility. Paminggir received a state electricity corporation (PLN) connection in 1999. Voices Of The Poor
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BAJO PULAU: Bajo Pulau is a small village with 380 households on a 91 hectare island off the coast of Sumbawa in Kecamatan Sape, West Nusa Tenggara. Most households depend on fishing. Two decades ago, they used explosives and potassium cyanide to fish; since 1987 they have focused on lobster and pearl harvesting, which provides better income. There is little infrastructure; there are no puskesmas or private doctors on the island. Clean water has to be brought from another island. There are three run-down primary schools, which function two to three hours a day. Schoolteachers and bidan desa do not live on the island; the Bidan is thus rarely available when needed.

ALAS KOKON: This village of 508 households is in district Bangkalan, Kecamatan Modung, on Madura island. It has a high 46 percent poverty rate by the BPS poverty map and 80 percent poverty rate by BKKBN criteria. The community, using local standards, puts the poverty rate at 67 percent. Households are dependent on seasonal dryland agriculture (corn, soybean, chillies, legumes and seasonal crops such as mango, banana and silk cotton—kapuk). Alas Kokon has one public and one private primary school. There is a Pustu/Polindes in the village; the Puskesmas is seven kilometers away. Clean water supply in dugwells is limited in quantity and sanitation access is minimal.

KERTAJAYA: Farmers grow five tons per hectare of rice in the fertile soil of the West Java village of Kertajaya in Subang district, Kecamatan Binong. Of the 1159 households, only 197 households are land owners; none of the poor (63 percent of the population) own land. The village has good access to markets and is connected to Subang, the district town, by bus or motorbike taxis. Houses of the rich on the main road have PDAM water connections others, including the poor, use dug wells. A puskesmas is five kilometers away; a bidan desa lives in the village. Kertajaya has two public and one private primary school.

ANTASARI: This urban kelurahan in Kecamatan Amuntai Tengah, district Hulu Sungai Utara, has poverty rates of more than 30 percent (BKKBN). The population is a mix of people from various parts of Kalimantan and Java, Sumatra and Sulawesi. The Kelurahan has 1,243 households engaged in a variety of trades and services. The poor in Antasari are mostly wage laborers in markets, at construction sites, and seasonal fishers in the river. Education and health is accessible (two public primary schools, one public secondary school, a puskesmas). Although PDAM provides piped water to homes of the better off, the poor are not connected.

JATIBARU: The urban kelurahan in Bima city in West Nusa Tenggara Province is located in a flood-prone area. The livelihoods of 1,886 reflect an urban/rural mix: in the agricultural season the poor are wage laborers in farmlands of neighboring Bima city, in other seasons they collect and sell fuel wood or work as vendors or day laborers in brick

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

kilns and factories. Jatibaru has five public primary schools, two public secondary schools, and one Pustu served by three health workers; a Puskesmas and a public hospital are within two kilometers. The poor get their water from unprotected dug wells and shallow bore wells; a piped water system built by CARE has fallen into disrepair: “The community has no funds to repair” was the reported reason.

SIMOKERTO: Simokerto is an urban village in kecamatan Simokerto, district Surabaya, in East Java Province. The Voices Of The Poor village, 10 kilometers from Surabaya, situated in the middle of commercial and industrial areas, has a 90 percent poverty rate (BKKBN). There is little social cohesion among the approximately 3,500 households: some live in a squatter settlements on land owned by the state railways. The poor struggle to survive through a variety of work. There are no health services in Simokerto, but Pustu and Puskesmas are nearby. Simokerto has eight public primary schools, two private primary schools and a private high school. The nearest secondary school is three kilometers away. A few rich have PDAM connections. The rest buy clean water from vendors. The poor mostly use dug well water. Some houses have unimproved sanitation facilities that directly discharge into drains and black-colored streams. Poor squatters have no sanitation access except one public toilet.

SOKLAT: Soklat is an urban village of 2,881 households. 54 percent of the households is poor (local criteria) in kecamatan and district Subang, West Java Province, three kilometers from the Kecamatan capital. Though classified as urban, the region has irrigated rice cultivation and about 40 percent of poor households’ income is derived from agricultural labor. Others work at construction sites, in shops, or pull carts as transportation laborers. A large proportion of poor households send members overseas for wage labor. Agents regularly visit the village to recruit people and provide loans for travel expenses, thus binding the recruited people into exploitative service agreements.

2. Education Services Used by the Poor
2. 1. Primary Schools: Not Really Free – Despite Government Provisions
Lack of education is a basic fact for the poor in Indonesia. At six of the eight sites, the poor cited one of the characteristics of poverty as: “Children of poor households are often not enrolled in primary school/do not complete primary school/just manage to finish primary school.”

In July 2005, the Indonesian government promised to provide nine years of free basic education for all school aged children via Operational Aid for Schools (BOS) grants. Nonetheless, the poor still pay hefty entrance fees (sometimes called building fees), particularly in Java (see Annex 3, Table 3.1). Although students reportedly are no longer paying monthly tuition fees (which ranged from Rp.2,000 – 17,000 per month), cost of books, uniforms, fees for computers, examinations, and certificates can add up to Rp.100,00 – 150,000 per child per year. Additional “hidden” costs include shoes (required by some schools), school bags, snacks, etc. (see Annex 3, Table 3.1).

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Top Choice: SDN
The poor prefer public schools. At most sites there was some choice among several government-run primary schools (Sekolah Dasar Negeri or SDN), and in some cases also community-managed Islamic schools (Madrasah Ibtidaiyah). At seven of the sites the primary school chosen by most of the poor was the SDN. The factors that the Voices Of The Poor
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poor mentioned in making this choice were: • • • • The SDN is near home; no transport costs; children can go alone; no need to cross main roads. SDN is free for the poor. Teachers are good; children learn many things in SDN. In Madrasah they get only religious teaching. Children finishing the SDN receive a certificate.

The only site where the Madrasah was preferred was Alas Kokon in Madura. Parents’ reasons for this choice: • • • The Madrasah does not require costly uniforms. Teachers are more disciplined and regular at the Madrasah. The SDN teacher is often absent/not disciplined SDN only teaches children to read, write and count. At the Madrasah they also learn religious practices and Qur’an reading.

Poor men and women generally think the benefits of primary education at public schools outweigh the costs (see Figure 1 and Annex 3, Figures 3.1 and 3.2,). However, paying for that education, particularly when there are several children, is a challenge.

Satisfaction ratings depend on the quality of individual teachers and the degree of transparency in the school’s financial dealings with parents (see Box 1).

The Burden of Additional Fees
The poor feel burdened by the cost of schools: - “Why must books be changed every semester?”, - “Why not have books that work for the whole year?”, - “Why do school books cost so much?”, - “Why are we charged for certificates?” are recurrent questions. Unpaid entrance and certification fees pile up. Schools increase the burden by withholding passing certificates from defaulters, causing frustration and friction between poor parents and school authorities. Even the kepala dusun (head of hamlet) of Simokerto had trouble paying the registration fee (typically kepala dusuns are better off than the rest of their community). Only one of his three children received the school certificate after full payment of the Rp750,000 (US$75) fee, roughly equivalent to three and a half months income of a local poor household.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Figure 1. Proportion of votes for choice of provider for primary education services
Women’s View Men’s View

14%

22%

Voices Of The Poor

86%

78%

SD Negeri

Madrasah Ibtidaiyah

Education costs at the SDN vary widely among the sites (see Annex 3, Table 3.1). In Paminggir (South Kalimantan), school is almost free with only nominal enrollment and school completion certificate fees; in the Surabaya slum, enrollment fees and books amount to Rp.830.000.5 At West Java sites, parents pay 10 to 15 times more than elsewhere to obtain primary school completion certificates. At Soklat, the men’s group complained that despite having paid Rp.68,000, they still had not received the certificate. (In comparison, the privately run Madrasah Ibtidaiyah costs only Rp.5,000 – 10,000 per month).

Box 1. No Explanation of Fees
“We heard that in SDN Cibarola, at the time of getting the certificate, all the parents were invited to a meeting and informed that it will cost Rp. 60,000. They were also informed of details of the cost. But in SDN Ds. Samsi, we parents were never informed nor invited to any meetings. I have contributed several times – the total comes to Rp. 68,000. Why is it more than in SDN Cibarola? I asked the school principal but I was not heard. And the certificate is still not given. Every time I ask, the principal says – later, later”. Father of a child finishing primary school, Soklat, West Java

2. 2. Secondary School Education Services
“Free? What free? We don’t have to pay monthly tuition now, but we have to buy books and uniforms and pay building maintenance fees. In the past we just paid Rp.10,000 – 20,000 every month and nothing else. Now we have to spend Rp.200,000 at the start of the year.” - Vegetable vendor and mother of two school children in Jakarta Reported in The Jakarta Post, July 17, 2005

5

Registration or building fees range from Rp. 50,000 – Rp.100,000 per child at the NTB urban and West Java rural sites. The fees, which may be paid in installments, reportedly cause many students to drop out. In addition, recurrent costs other than tuition (books, computer fees, uniforms, bags and shoes, etc.) added up to Rp.100,000 – 150,000 per year.

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Extra Fees a Problem, again
Public junior high school represents a major financial burden for poor families. Poor households try to send at least one child to junior high school—Sekolah Lanjutan Tingkat Pertama (SLTP) or Sekolah Menengah Pertama (SMP)— but can rarely afford to send all. Voices Of The Poor
7

Only three children from Kertajaya village go to secondary school — and that is an Islamic boarding school (Pesantren) outside the village. Bajo Pulau has no secondary school and no children are sent to study outside the village.

At urban sites Jatibaru, Simokerto and Soklat, respondents enrolled at least one child in SMP or Madrasah, whichever is available and not too far from home. They prefer the Madrasah as there are no entry or construction fees. Entrance, registration, and building fees are not fixed, ranging from Rp.200,000 – 600,000 (see Annex 3, Table 3.2). The schools charge whatever they can, depending on their reputation and popularity—and justify the fees on the basis of extra subjects or facilities offered. Reportedly, such charges have no legal basis.6 A comment from the men of Kertajaya sums up the parents’ frustration: “To enter SMP Negeri calls for at least Rp.1.5 million. On top of that, there are the costs of transportation, food etc. Who can afford it?”

Public Schools Most Popular, but Islamic Schools are Important
Pesantren or other Islamic schools (Madrasah Tasanawiyah) were chosen over SMP by 37 percent of the men and women in the study, and were the popular choice at two sites, Alas Kokon and Antasari (see Annex 3, Figure 3.3). Kertajaya and Bajo Pulau have no secondary schools and the remaining four sites chose the SMP available in the community.

In Alas Kokon and Antasari, parents who send children to the Madrasah Tsanawiyah (religious schools run by the Government Department of Religious Affairs) seem highly satisfied. In Alas Kokon, the school costs Rp.1,500 a month; in Antasari, annual fees are Rp.100,000, but all children received financial aid this year. It is a “model” school. Its services are complete and parents consider it very good value for money. The SMP in Paminggir (South Kalimantan) is free, but the quality of the school facilities and education are very low. Costs of the SMPs in Java and NTB are much higher (Rp.400,000 –600,000) (see Annex 3, Table 3.2).

When fees are charged the poor think that the SMP Negeri does not offer sufficient value for the cost, whereas the Madrasah Tsanawiyah does. Women are particularly dissatisfied because (see Annex 3, Figures 3.4 and 3.5): • • • The SMP is far from home – transportation costs are high / not on public transport route. SMP is expensive. On top of that, it costs another Rp.450,000 to get the completion certificate (Simokerto). The classrooms are shared with the primary school (Jatibaru).

6

According to the Director of Paramadina University Center for Education Reform, Hutomo Danangjaya, state schools need no additional building maintenance funds because they already have well-maintained buildings. Jakarta Post, July 17, 2005.
Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Lack of Secondary Schools Means Girls Must Marry
Girls’ lives are drastically changed when the secondary school is inaccessible either due to distance or cost. In these cases, the girls are married off soon after primary school and become pregnant just after they enter puberty (see Box 2). Maternal and infant deaths and disabilities are common in such pregnancies. Voices Of The Poor

Box 2. Married at 13, childbirth at 14 –the only option after primary school
On September 15, 2005 in Alas Kokon village on Madura, researchers met Nurhayati who is 14 years old. She had just given birth to her first child after three days and nights of difficult labor. She was first assisted by the local TBA, but later the bidan desa had to be called to help. She did not die—this time. In the absence of a secondary school in the village, every girl in the area is married off right after primary school; immediate pregnancies are inevitable, death is a high probability. How can Nurhayati and other young girls be empowered to gain any control of their bodies and lives? Site Report, Alas Kokon, Madura

2. 3. Quality of Services - Providers’ Views
Primary School Teachers’ Views
At seven sites the researchers met and interviewed teachers at state primary schools. At Paminggir, the night watchman was substituting for a habitually absent teacher.

Teachers at rural primary schools state that they are able to provide very little in terms of quality education. Schools have only two or three classrooms serving six grades. School buildings are in disrepair, but reports to the education department bring no results. Rural schools in remote places like Paminggir and Bajo Pulau island have trouble keeping teachers in school because of lack of basic services such as clean water and sanitation.

The teachers say that children tend to drop out and work, once they gain basic literacy and numeric skills. Parents see no value in further education for their children. Sometimes a school will provide incentives such as funds for transport or second-hand uniforms to encourage the poor children to stay in school.

The outlook of urban primary school teachers is much brighter. They believe they are providing very good value for cost to poor students. They recounted the many pro-poor measures in place in the schools such as scholarships and fund raising drives to pay for poor students’ uniforms, writing materials, and extra-curricular activities. In Antasari and Jatibaru they said that parents know about the quality of the school and the pro-poor measures. At two urban primary schools the teachers said that poor students do not have textbooks and suggested that the school should lend books to the poor students.

Educators’ and parents’ assessments sometimes are far apart. The principal of the primary school in Soklat exalted the quality of his school as “200 percent.” He emphasized that school administrators frequently interacted with parents,

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

maintained transparency of funds, and allowed poor parents to pay fees in installments. Poor parents disagreed, and complained that completion certificates were withheld and that information about waiver of tuition fees had not been publicized.

Secondary School Teachers’ Views
The state secondary teachers interviewed were in Soklat, West Java and Antasari, South Kalimantan. In Paminggir, rural Kalimantan, the village chief was serving as a volunteer teacher in place of the absentee state-paid teacher. Voices Of The Poor
9

The teacher in Soklat argued that education could not be totally free, although the school does consider the economic capacity of parents and allows them to pay the registration/building fee in installments. According to him, the issue of education costs is over emphasized: “If they just smoke one cigarette less a day, it would be possible to save enough to pay Rp. 15,000 a month for education.”

The principal of the Madrasah Tasanawiyah Model School in Antasari said government funds are sufficient to cover all fees and other study and extracurricular materials for students identified as poor. Poor parents gave very high marks for value and quality to this large school, which has seven to eight sections for each grade, totaling 23 classrooms. This school is funded by the Department of Religious Affairs.

2. 4. Independent Observation Results and Conclusions
Primary Schools- Quality of Service
Only state primary schools were observed. The four rural schools observed are in markedly poor condition, and delivering significantly lower quality services than the urban schools.

Although all primary schools are designed for Grades 1 through 6, rural schools had only two to three classrooms necessitating grades to group together. None of the rural primary schools had clean water; half had no sanitation facilities. Sanitation facilities at the other schools were present, but were damaged and unusable. None had electricity or a library. Three had damaged roofs.

At the four rural schools attendance on the day of observation ranged from 28-92 percent. Classrooms were dusty and littered, with damaged floors, but there were sufficient chairs, adequate ventilation, and daylight. Wallboards were the only classroom resources. No students’ work was displayed on walls. Frequently, students were left alone in classrooms, without a teacher. Discipline levels were low.

Teachers did not live in the village but commuted from urban areas, and were often late or absent. Their reasons: lack of clean water and sanitation services (Bajo Pulau, Paminggir, Alas Kokon), see also Box 3.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Less than a quarter of the students in observed classes had textbooks and writing material. Teachers showed very limited questioning skills and did not generate interactions with students. No student asked any questions in any of the classes. Teacher displayed no gender bias in dealing with students, and used a mix of Indonesian and the local language. Voices Of The Poor

Box 3. No clean water equals no schoolteachers and health workers in the village
Pak Sahrul, the school watchman/stand-in teacher at the Paminggir public primary school says government-employed teachers (Guru Negri) are frequently absent. “I enter the class and teach whatever I can when the teacher is not there,” he says. “It is better than letting the children waste their time.” Sahrul says teachers live in towns, far away from the village, even though they have been provided free lodging. Paminggir has no clean water supply and everyone has to use the river water for all purposes – cooking, drinking, washing, bathing, as well as defecation. The Guru Negeri from the towns are not used to this. They return to the city to do their washing and are often late to report back to work. Site report, Paminggir, South Kalimantan

Box 4, illustrates why students and parents do not value the education being provided at a rural primary school in NTB.

Box 4. 92 Enrolled but 29 present
Tison dropped out of primary school in grade five to help his family by working as a ferry boat operator. He now earns around Rp.100,000 (US$ 10) month, giving most of his earnings to his father. When asked why he preferred work to attending school, Tison said he had already learned to read, write and count and wasn’t learning much else. Teachers came from the mainland, arrived late at 9 and sent the children home at 11 a.m.. School dismissed at 11 a.m. Grades 2, 3, 4 and 5, 6 were grouped together, consequently they were unruly and too big to manage. Surroundings were dismal: no water or sanitation facilities, not enough chairs, and leaks in the roof. On top of that, Tison was bored. On the island boys generally drop out of school between the third and fifth grade, leaving mostly girls enrolled in primary school. On the day researchers visited the school, only 29 out of the 92 children were present. Site Report, Bajo Pulau, NTB

Urban Primary Schools: In contrast the urban schools were markedly better than their rural counterparts in terms of facilities as well as teaching processes.

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Illustration 1: The Urban/Rural Divide: Conditions are good at urban state primary schools, as exemplified by the class in Soklat, West Java (left) and the school in Simokerto, East Java (right), which has a library

All four urban primary schools (SDN) had a reliable clean water supply. Sanitation facilities, while present and functional, were minimal, with only one or two toilets serving up to 200 children. All schools had electricity and sufficient classrooms, but only two had a library and a sports field. Two claimed to offer computer classes. Classrooms observed were clean, well ventilated, and in good condition. Basic classroom resources like blackboards and wall charts were present and used whilst chairs and tables for students and teachers were sufficient.

Student attendance rates on the day of observation were a high 87-100 percent. At two sites, there were significantly fewer girls than boys.

Less than a quarter of students in observed classes had textbooks, copybooks and writing materials. The one exception was SDN Murungsari 2 in Antasari, South Kalimantan, where more than three quarters of the students had and used these learning materials during the class

Teachers present in all classes were well prepared and skilled in asking questions and engaging students’ attention. Students, however, asked questions at only two schools. The teachers used local languages combined with Bahasa Indonesia, checked for student understanding, did not display gender bias, and controlled their classes well.

Secondary Schools: Quality of Service
In general, the quality of facilities available and education processes of state secondary schools were far superior to those observed at state primary schools. Secondary schools were available and observed at all four urban sites, but only at one rural site (SMP Negeri in Soklat, Simokerto, Jatibaru, Paminggir and Madrasah Tasanawiyah Negeri Model in Antasari).
Illustration 2: Classrooms in the rural state primary school of Bajo Pulau devastated by storms and flooding three years ago.

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Voices Of The Poor

School buildings were permanent constructions; classrooms were in good condition, well ventilated, and adequately lit with natural light. All urban schools had electricity and clean water supply available. Remote, rural Paminggir’s school was supplied with river water pumped up to the school and generator-provided electricity. Two of five schools seen had libraries. In three schools, two toilets were meant to serve 200-300 children and in all these cases the toilets were broken. In two other schools six to eight toilets were well maintained. A separate toilet was allocated for teachers. Voices Of The Poor

The secondary schools had 6-23 classrooms at different sites. Except in Jatibaru (Bima) they were clean and in good condition. On the day of observation, classes had upwards of 92 percent attendance everywhere. Girls significantly outnumbered boys present (see Table 2). Reasons were not clear and warrant further investigation.

Illustration 3: Rural conditions are not conducive to learning. At state primary school in Alas Kokon, grades 2, 3, and 4 are combined in one room. Children amuse themselves—sometimes becoming quite rowdy— because the teacher is absent.

Illustration 4: Urban state secondary school, Subang, West Java

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Table 2. Secondary school observations at different sites Present in observed classes Girls Paminggir (South Kalimantan) Antasari (South Kalimantan) Jatibaru (NTB) Simokerto (East Java) Soklat (West Java) 23 29 21 35 21 Boys 15 11 16 23 Voices Of The Poor
13

8

More than three-quarters of the students were equipped with copybooks and pen or pencil, fewer than a quarter had textbooks. Teachers appeared well prepared for their lessons. At two sites teachers taught only in Bahasa Indonesia. At other sites they combined it with local languages.

Conclusions
1. Quality of primary education service in rural areas was observed to be very poor. The condition of the school infrastructure was not conducive to learning.

2. Providing incentives to poor households for secondary schooling of girls or making it easier to send girls to secondary schools can be a strategically important investment to delay teen pregnancies, give girls an opportunity to gain control over their lives, and improve human development outcomes in Indonesia.

3. Teacher absenteeism was a key problem in rural areas that lacked clean water and sanitation—which reportedly makes teachers from urban areas unwilling to stay in the villages. When they are absent, children are let out of school, left in classes without teachers, or taught by teacher substitutes who have no training in teaching methods and education levels no higher than secondary school. Most primary school students lacked textbooks and writing materials, which lowered the quality of teaching and learning.

4. Lack of clean water and sanitation facilities in rural primary schools also made it impossible to inculcate basic hygiene practices. Children observed had poor personal hygiene.

5. Urban state primary schools were better than rural schools in terms of basic infrastructure, except for sanitation. Urban primary schools had teachers with adequate teaching skills. Most students lacked textbooks.

6. The quality of infrastructure and educational facilities, as well as the quality of teaching at the secondary schools were far superior to those at the primary schools. This, however, made little difference to the poor since, according to the study, children from poor households rarely progressed beyond primary school.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

7. Out of all the schools observed, the state primary school (SDN Murung Sari 2) and the state secondary school (Madrasah Tasanawiyah Negeri Model, Sungai Malang), both in Antasari, seem to stand out above the rest, followed by SMP in rural Paminggir. Ironically, these schools were charging the lowest fees and offering the most scholarships for poor students. All three schools are located in South Kalimantan. Parents are highly satisfied with these schools, probably because the local government in South Kalimantan seemed to have made a dedicated effort to fund quality education for the poor with a higher per student budget allocation than at other sites. Voices Of The Poor

3. Health Care: Prenatal, Childbirth, & Child Health Services
The availability and affordability of the services and poor people’s perceptions of value and quality determine the choices they are making. Typically, women make decisions about providers; men are involved only when expenditures rise above Rp.10, 000. Each choice is highly rational, based on weighing of benefits and costs as perceived by the poor. Policies to improve service delivery to the poor can be effective only if they are cognizant of the ways and reasons the poor make their choices.

During the 1990s trained nurse-midwives (bidan desas) were introduced all over Indonesia in an attempt to lower high maternal mortality rates. A decade later, bidan desas do not seem to have caused a large shift in the poor population’s preference away from the traditional birth attendants (TBAs) for obtaining childbirth assistance services.

3. 1. Prenatal Services: Preferences Vary with Geography
Approximately 65 percent of all the poor surveyed use public sector providers, i.e. the bidan desa, Puskesmas or Pustu, while the remaining 35 percent use the traditional birth attendant known by various names such as dukun bayi, dukun beranak, sando, paraji, bidan kampung (see Figure 2).

The TBA was the most popular choice at all sites outside Java. At the Java sites, both rural and urban, the bidan desa or the Puskesmas/Pustu were preferred choices, except in Alas Kokon village on Madura.

Generally the pregnant woman or older female members of the household chose the ANC service provider. Costs of the most used option and its closest comparators are shown in (see Annex 3, Table 3.3).

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Figure 2. Proportion of votes for choice of provider for ANC services
Women's view 1% 26% 34% 23% 35% Men's view 1%

29%

10%

26% 14%

Sando/Bidan Kampung/Paraji/Dukun Bayi Bidan desa/Polindes Posyandu

Pustu Puskesmas

The poor who use the TBA for ANC services are aware that she is not well equipped to detect or deal with high-risk pregnancies and that she does not supply vitamin supplements or TT immunization. They nonetheless chose the TBA for the following reasons: • • • The TBA is always available, whereas the Bidan is rarely in the local Polindes or Pustu. The TBA lives near their homes, while the Puskesmas is far away and requires costly transport. The TBA charges Rp.1, 000 to 5,000 per visit, sometimes just payable in rice or coconuts; the Bidan’s fees are three to five times that (Alas Kokon.) • • • The TBA knows how to change the position of the fetus “if the head is not in the right position”. She is experienced, has delivered many healthy babies in the past. She is trusted and familiar.

At the Java sites where the Puskesmas and Pustu are more accessible, the poor preferred to make use of the inexpensive public sector services. For Rp.2, 500 – 5, 000 they can get ANC examination, iron supplements as well as TT immunization, and can also find out whether the pregnancy is likely to be risky. Women prefer to contact the bidan desa in the evening at the Bidan’s home for ANC services, because service is attentive and there is no waiting. Costs, however, are five times greater than the Puskesmas service when transport costs are added. Even on Java, the poor spend Rp.6,000 – 12,000 on transportation to access ANC services, which cost Rp. 3,000-5,000 at the Puskesmas or Rp. 10,000-15,000 at the bidan desa’s home.

Generally, ANC services from the TBA seem to provide the most value for money to the poor. The Puskesmas comes second in this respect and the bidan desa, working from her home, is the third. (Annex 3, Figure 3.5, shows how the poor rated the benefits of using each service provider and the extent to which they felt the benefits to be worth the costs7 ). The TBA’s services are considered by women to be worth a lot more than the cost incurred (Bajo Pulau,

7

Benefits and Value for Cost is a tool from the Methodology of Participatory Assessment (MPA) repertoire. For explanation see Sustainability Planning and Monitoring in Community Water Supply and Sanitation. Mukherjee and Van wijk , WSP-IRC-World Bank. 2003
Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

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Voices Of The Poor

Alas Kokon, Jatibaru). Yet, at least at all the Java mainland sites, the poor were choosing the Puskesmas or the bidan desa for ANC services rather than the TBA. They did this in order to minimize the risks of complicated labor and large unexpected expenses during childbirth – through timely detection of possible high-risk pregnancies.

3. 2. Childbirth Assistance Services: TBA Still Reigns Supreme
Voices Of The Poor Fees per birth assisted: SOKLAT / West Java Paraji (TBA): Rp.50,000 - 100,000 or Rp.50,000 + 5 kg rice Bidan Desa: Rp.300,000 - 400,000 As long as the birth is expected to be normal, the TBA is the most popular and obvious choice everywhere. Barring the big city slum site of Simokerto, at every site the TBA was the first choice among women (76 percent) and men (64 percent). (See Annex 3, Figure 3.7) Although the most obvious reason seems to be the

differences in costs, there are several other factors favoring the TBA. The bidan desa’s services for childbirth cost more than an average poor household’s monthly income, and have to be paid for in cash. In contrast, the TBA can be paid flexibly in cash plus in-kind, at a rate about one tenth to one fifth of the Bidan’s rate. The TBA is also willing to accept deferred and installment payments – as and when the family can pay (see Soklat and Annex 3, Table 3.4).

More importantly, the poor are better satisfied with TBA’s services and feel they receive value for their money (see Annex 3, Figures 3.8 and 3.9). The TBA is reported to be more caring and patient than the Bidan, both during labor and after childbirth. Poor women say the TBA would continue to serve for 10 - 44 days postpartum, lovingly pampering the new mother and the baby. She takes on all the washing and cleaning up after birth, sparing the family members and allowing the new mother to rest and recuperate. In contrast, the Bidan is said frequently to be unavailable when needed or even unwilling to come when called (Bajo Pulau, Paminggir, Alaskokon, Jatibaru). When she does come, she assists only up to the delivery of the baby and the placenta.

The poor recognize that the Bidan is better equipped to handle difficult deliveries, but at six of the eight sites, the Bidan is called only when the TBA is unable to deliver due to complications during labor, a practice that often leads to fatal delays.

Professional jealousies further threaten the health of the mother and baby. The poor report that the bidan desa is often unwilling to respond if the family has previously used the TBA’s services, and instead tells the family to go to the Puskesmas or the public hospital. In West Java, the bidan desa has made a condition that if people want help from the Bidan, they must call both the TBA and the Bidan to attend childbirth so that the Bidan can control the process from the start. This however implies that the household incurs double charges.

The poor are seldom aware of possible problems during pregnancy or childbirth (see Box 5). They depend on their chosen service provider (most often the TBA) to take action or refer the pregnant women to better health facilities. The health care system fails to alert the poor to the danger signs of pregnancy or childbirth and what actions to take.

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

The public hospitals in Java and the Puskesmas are deemed to provide the most satisfying services (see Annex 3, Figure 3.8) but high costs keep the people away. The Puskesmas and the public hospital are used only in lifethreatening emergencies.

Box 5. Pregnancy danger signs unrecognized
Tasiah, 36, fell down in her sixth month of pregnancy with her third child. She had visited the Posyandu and the TBA for ANC check up, but did not report her fall and no one asked or reviewed risks. The baby was stillborn, dry and deformed at birth, and TBA said that there was no water in the womb. The fall may have broken the amniotic sac long before birth, without the mother realizing it. Site Report, Paminggir, South Kalimantan

3. 3. Curative Services for Young Children (< 5 Years): Public Services are the Preferred Choice
At all the sites the poor tend to prefer public sector services for curative services for infants and under - fives. They cite: better diagnosis, faster recovery, and affordability. From 80 to 85 percent choose public sector providers for children’s’ health care mainly the bidan desa and Puskesmas (see Annex 3, Figure 3.10 and Figure 3.11). At urban sites, the Puskesmas or the Pustu is the first choice, at rural sites bidan desa or Pustu. Although private doctors are perceived to provide better services, their fees are prohibitive (Soklat, Bajo Pulau).

Only the island community of Bajo Pulau, NTB, prefers the TBA. One reason is practical: the bidan desa was “never available in the village”. Another relates to beliefs: according to local traditions, babies delivered by the sando (TBA) are considered to belong to her for the first 44 days of life and she takes care of them free of charge.

The poor consider a number of factors in choosing a health provider for their children under 5 years. Their most important requirements echo their concerns regarding prenatal and childbirth services. The provider should: • • • Be available when needed. Be close to home /no or low transportation costs. Prove affordable/good value for money (true mainly of the Puskesmas, since the bidan desa or mantri do not accept Kartu Sehat outside the Puskesmas). • Examine sick children thoroughly. When parents take the trouble to travel to the Puskesmas, their children should get to see a doctor rather than paramedics. • • Only give medicines that are effective and clarify how long treatment is necessary before results can be seen. Explain to parents the nature of the illness and provide advice on how to care for the child (diagnosis, prescription, medicines, immunization, supplements etc).

The poor consider their choices, and tend to make them by the degree of severity of the problem. They know that the quality of service from the TBA is insufficient, but traditional healers are still consulted for minor ailments. The comment of one parent was typical: “Traditional healers can only pray, offer massage, and herbal remedies, but can rarely guarantee quick recovery.”

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

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Voices Of The Poor

The poor say the costs of consulting traditional healers and Pustu or Puskesmas are comparable, however they note transportation to the Pustu and Puskesmas can significantly raise the cost of seeking Pustu or Puskesmas services (see Annex 3, Table 3.5).

In the villages, the poor with a Kartu Sehat (Health card) are attracted to the Puskesmas or Pustu, where they only pay a “registration” fee of Rp.2,500 to Rp.3,000 to access services and free medicines. In Simokerto the Pustu “registration” Voices Of The Poor fee costs Rp.5,000 according to the poor, but Rp.3,000 according to service providers.

The previous points out a big problem in health care delivery for the poor. By law, the poor with a Kartu Sehat should receive services and drugs at the Puskesmas for free. By charging a “registration” fee, the Puskesmas are collecting fees illegally. By lacking information about set fees, the poor are consistently overcharged.

Services from the bidan desa at her home are highly rated, although the charge is roughly double, Rp.15,000: “There is no need to wait in long queue and the medicines are more effective.”

If the child is still not cured, parents next consult the paramedic (mantri), who charges Rp.25,000 - 50,000, or a private doctor at an average cost of Rp.40,000 - 70,000 per consultation, in addition to the cost of prescribed drugs. The private doctor was the most satisfying option: “He gives medicines that make babies recover fast. One visit to the private doctor is enough to the cure the baby.”

(Annex 3 Figure 3.12, shows how the top choice among service providers at each site measured up in terms of benefits versus costs, in the perceptions of the poor clients).

3. 4. Quality of Health Services Being Delivered to the Poor
Observations by the Poor
Predictably, considering the fact that women are more involved than men in the care of sick infants, there is a gender divide in satisfaction ratings of various providers (see Annex 3, Figure 3.13). Women are less satisfied than men with services of the bidan (Soklat, Kertajaya, Bajo Pulau), the Pustu (Paminggir), and the Puskesmas (Soklat). While men tended not to explain their ratings, poor women had many insights to offer about their experience.

Concerns about the bidan: • “Why pay more at the bidan’s house, when she is the same one providing service at the Puskesmas [where it is only Rp.3,000]?” • • “More than two to three times the cost of the Puskesmas” “Ibu Bidan is never available when we need her.”

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Reasons for women’s low satisfaction with the Pustu: • • • • • “Workers are often not available, without prior information.” “Medicines given are not effective.” “We have to wait long in queues, even with a seriously ill baby.” “The workers just write down prescriptions and don’t explain how to give the medicines.” “They don’t tell the parents what is the baby’s illness and how to take care of the baby at home. They are always in a hurry to finish with one patient and go to the next.” • “Paramedics often make only cursory examinations for less than five minutes. Sometimes, they don’t examine the child at all and simply prescribe medicines after asking parents about symptoms.” Voices Of The Poor
19

Dissatisfaction with Puskesmas: • “At the Puskesmas those who examine the baby are not doctors, they are either the bidan or the mantri. There is no doctor specialized for anything at the Puskesmas.” • “For all illnesses they just give the same medicine. Often for babies they just give us a powder. I ask ‘Doc, what is the fever my baby has?’ He says ‘Many things, mixed up’.” • “They never explain the illness, or the medicine given to the patient. ‘If not better, come again next week.’ But if I come again – the medicine will be the same again.”

Traditional Birth Attendants’ Observations on Quality of Care
TBAs were interviewed in rural Paminggir, Alas Kokon, Kertajaya and urban Soklat regarding their opinions of the quality of services they provide.

The TBAs feel they are providing high quality, affordable ANC and childbirth assistance services. They say their poor clients are highly satisfied, and see no need to improve their service. The Paraji in Kertajaya summed it up: “Helping childbirth is our sacred human duty. People pay us whatever and whenever they can – rice, coconut, sugar, money. We provide service for 40 days after the birth, day and night. That is why the poor are so happy with us.” The respondents’ votes for choice of ANC and childbirth assistance in this study certainly confirm the truth of her statement.

Two of the four TBAs interviewed had received training from Puskesmas doctors in 1990-91. They had found the training and the birthing kit given with the training to be useful.

An indication of how tight funds are: the TBAs are still using the same instruments – namely a pair of surgical scissors to cut the cord. They wondered why training was no longer available, and suggested that the government should provide them new birthing kits and a scale to weigh newborns.

The other two TBAs (in NTB and Madura) had refused the training and birthing kit. “I am too old to learn new things and I don’t want to carry books and bag”, said the TBA from Madura. “My experience and traditional knowledge are enough for my job.”

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

This attitude probably reflects the uneasy relationship between the TBAs who are old and respected members of the community, and the bidan desa, a trained government employee from outside of the community, often younger in age. Ideally the two should work collaboratively, but in reality, the TBA is reluctant to admit that the bidan desa is better able to deal with difficult childbirths; consequently, references are sometimes tragically delayed. Voices Of The Poor

Still, TBAs do see a need for improvements in the public health sector. The TBA in Paminggir said: “We need health workers, Bidans and doctors who are willing to stay in the village, or at least visit the village on a definite weekly schedule.”

Bidan desa (Village Midwife) on Quality of Service
Bidan desas at six sites were asked their views about the issue. They said they were doing the best they can, but observed that there is little demand for their services among the poor. Bidan Liliek in Kertajaya explained: “Some of the poor choose my service because it is complete. I can detect pregnancy problems. I provide TT immunization and vitamins. My ANC service fulfills standards.”

Bidan desas think they are charging fees commensurate with their services. They say that the poor unrealistically consider them too high: “The poor expect miracles if they pay anything”, said Bidan Windarti of Alas Kokon. The Bidans said they do adjust their fees to their clients’ ability to pay.

The bidan desas have several recommendations for service improvements that the government could make: • More poor people need the Kartu Sehat or Askes insurance card. Often, when the Bidan refers the poor to the hospital in an emergency, the clients do not have a health card. • Increase the number and quality of drug supplies at the Puskesmas or Pustu, which the poor can access through use of the Kartu Sehat.

Puskesmas/Pustu Bidan and Paramedics on Quality of Service
Urban Pustus (sub-health centers) may be losing customer bases. The Bidan in Simokerto said that only the poor came to the Pustu, but even their attendance was falling. She suggested the center’s limited hours “might clash with their working hours…. We used to serve up to 70 patients a day at this Pustu. Now it’s only 20 to -30 per day.”

Remote areas are more problematic: The mantri (paramedic) makes weekly visits to Bajo Pulau island to seek out patients; people don’t visit the Pustu on the mainland. The mantri says people call him on his cell phone only if someone is seriously ill.

Poor people can rarely find the bidan or the mantri in the Pustu in Paminggir. The mantri said “I cannot stay in the village as I have many tasks in the city.” The bidan desa, his substitute, doesn’t stay in the village either, because she is reportedly preparing for the Haj. The villagers do not consider these reasons for their absence justifiable.

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Puskesmas Doctors’ Views of Quality of Service
Three Puskesmas doctors were interviewed in West and East Java (Madura) and NTB regarding services available and their quality. Voices Of The Poor
21

The doctors agree that the Puskesmas is valued by the poor mainly as a place to get free medicines and cheap health services. They note that, in the past, medicines were in short supply, but now the Puskesmas is authorized to buy medicine supplies using funds leftover from annual budgets. They worry that the poor have an impression that generic medicines, which are sold or distributed without branded packaging, are less effective than the branded ones. The doctors were divided in their opinions about the quality of service provided by health workers to the poor. At both the West Java sites they said the health workers provide good service at the Puskesmas; interact with poor clients at Posyandus; and are trained in “quality assurance procedures”. According to them, one reason why the poor are not fully satisfied with the clinics is because they are located far from their communities, which makes transportation expensive.

All doctors state that the Kartu Sehat health cards have not been properly targeted at the poor. Many who have and use it are well off, while a lot of the real poor still do not have Kartu Sehat or health insurance (Askes Card). Listing and registration for Askes began in January 2005 and is not completed at the time of this study (October 2005). With fixed and inadequate quotas of clients per Puskesmas, Askes will not be available to all who need it.

The physician in the peri-urban Puskesmas in NTB said most of the outreach health workers were not providing good quality services at the community level. To improve service quality he suggested the Depkes (Ministry of Health) should: • Establish practical performance indicators for health workers, which can be easily understood and verified by them and their clients. • Institute rewards and sanctions for health workers as done in the private sector. Use standards like total patients served per day. • • Deduct from health workers’ salaries when they are absent. Publicize the rights of the poor to health services through mass media.

3. 5. Independent Observation Results and Conclusions
The study included an independent assessment of service quality and compared this with established norms. The following conclusions draw upon assessments by the poor, by service providers, and the independent assessment using observations guided by checklists.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Ante Natal Care
The study reveals heavy use of the TBA for ANC and childbirth. This is not only because TBAs’ fees are low and they are available, but also because the poor perceive the quality of their services to be high.

Voices Of The Poor

Poor men and women have little understanding about what constitutes good ANC services, and poor pregnant women do not see periodic antenatal care as a priority. Their TBAs are generally not familiar with the pathological events that may develop during pregnancy. The result is poor identification and management of maternal complications or risk factors, and a failure to benefit from protective services like TT immunization and iron supplements. This leads to elevated risks of maternal deaths, stillbirths, and neonatal deaths (See example in Box 6).

Box 6. Repeated premature births, no ANC check ups
Sri Wahyuni went into labor and delivered her first child at only seven months of pregnancy. She was delivered at home by the local TBA. The baby weighed only 2 kilograms, had difficulty breathing, and the TBA could not clear her respiratory passages. The baby lived for only two hours. Sri Wahyuni and her husband had no money for pregnancy check ups and had never gone to the Puskesmas for ANC examination. The following year, Sri got pregnant again, did not go for ANC check ups, suffered greatly from nausea during pregnancy and again went into labor in the 7th month. The second baby was born alive, weighted only 1.4 kilograms and also did not survive. Sri and her husband have given up trying to have a child. They don’t have money for pregnancy treatments, and are afraid of the mishap repeating itself. Sri is using contraceptive injections every three months. Site report, Simokerto, East Java

ANC by the TBA usually consisted only of determining the position of the fetus (with corrective massage if indicated). Several undetected fetal deaths, maternal deaths, and stillbirths were attributed to this practice and the consequent late referral for clinical intervention. TBAs lack of formally documented professional skills. For example, their level of training does not allow them to make reliable estimates of delivery dates. The failure to follow standard care, e.g., not giving tetanus toxoid immunization, results in infant deaths (Box 7).

The positive trend is that nearly two-thirds of the women and men interviewed reported using one out of three other types of public service providers, i.e. going to the Puskesmas, Pustu or the village–based midwife. The need to get the tetanus toxoid immunization for the pregnant mother was one reason they made at least one visit to public service providers.

The observation checklists revealed that services provided by trained village midwives are relatively good. In general, they follow the minimum standards. However, they tended to ignore the importance of health promotion/education. During the initial evaluation of the patient, they tended not to ask about the profile of the client, their obstetrical and other health histories, and their socio-economic status. This could be due to the provider and the client knowing each other as neighbors. Alarmingly, none of these providers washed their hands before examining clients. Physical examination by the midwife consisted only of measuring the height of the uterus and the weight of the mother.

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

They did not check the breasts, extremities, head and neck. Midwives usually provided tetanus toxoid immunization and iron tablets. However, the midwives usually had to resort to purchasing these supplies themselves and charge costs to their clients, resulting in fees higher than those charged by the TBA.

Box 7. No longer possessed by the devil
Between 1990 and 1996, 16 babies died in Rancajaya village. People believed that the devil possessed them. All had the same symptoms – convulsions, high fever, their bodies turning stiff and bending like a bow. All were delivered by the local traditional midwife, who used a bamboo knife to cut the umbilical cord. None of the mothers had received TT injections nor had the babies been immunized. When the babies got sick their mothers took them to the midwife who massaged the child and prayed for its recovery. Ibu Rusmini lost 3 children in this way, at 9 months, 1 month and 2 weeks. Today, in 2005, people are aware of tetanus and try to get TT immunization for pregnant mothers. They however still use the services of the TBA for childbirth. The TBA still cuts cords with a sharp piece of bamboo, which she now boils before use. Site report, Kertajaya, West Java

During ANC examinations by the village midwife at or outside health centers, no women were informed about those set by danger signs during pregnancy, which should prompt them to seek immediate care from trained health service providers.

Childbirth Assistance
The study showed that most people were keen to use TBAs, as their definitions of quality service differ from those set by medical standards. The primary shortcoming of this seemingly superb service is the failure of most TBAs to meet minimal medical standards, such as using non-sterile practices, e.g. cutting the umbilical cord with a bamboo strip and aspirating the newborn’s nasal passages by mouth.

The case histories of maternal and fetal deaths in this study illustrate what happens when the TBA fails to respond to the danger signs during pregnancy and labor and delays referrals (see Box 8).

Box 8. Four days too late …
On Bajo Pulau island off the Sumbawa coast, Zubaedah was pregnant with her second child when she experienced abdominal pain and bleeding in her third trimester. According to the sando (TBA) it was still too early for labor and the bleeding was “nothing much to worry about.” The wife of the head of the dusun (Sub-village habitation), a trained midwife, thought the baby was already dead and urged the family to take Zubaedah to the hospital, but they refused. After Zubaedah continued to bleed for two days, the family decided to contact the bidan desa. She arrived a day later and, after examining Zubaeda, the Bidan referred her to the hospital. After the journey to Sape by boat and rented horse carriage, Zubaedah was examined by doctors, who decided to operate to extract the baby which had died because the placenta was blocking its passage out of the uterus. Before the operation could begin, Zubaedah, exhausted from four days of bleeding, died. Site Report, Bajo Pulau, NTB

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Voices Of The Poor

Curative Treatment for Children Under 5
The health center (Puskesmas) is the preferred provider. People consider it inexpensive and reliable. Nonetheless, convenience compels most of them to bring sick children first to village midwives or paramedics available in the village. When the poor take the time and incur expenses to go to the health center, they hope that their children Voices Of The Poor will be examined by doctors or even specialists, not just paramedics and the midwife. Examinations by the latter are considered too rushed (confirmed during independent observations using a checklist devised by a doctor).

Assessment and classification: Observation results reveal that very few sick children seeking care at the health center were fully assessed and correctly treated by the midwife and paramedics. None of these providers washed their hands before examining a sick child. Moreover, the quality of assessment and classification of illness when measured against the IMCI standards was low. Only one health care provider checked for the three danger signs. This was at the one center staffed by a doctor, and even he only checked for two of the three standard signs.

Treatment: In the absence of definitive diagnoses as the basis of judging the quality of treatment, the data cannot gauge the appropriateness of treatment in this study.

Advice and counseling given: The study reveals a pervasive absence of health education services at every level of care encountered by pregnant women, new mothers, care givers of infants and sick children. Providers did not explain their diagnoses nor did they advise parents/guardians about ways to care for the sick children. If an explanation was given, it was hurried and one way. Before moving on to the next patient, they rapidly stated instructions about medication to be given but did not check whether the explanation had been understood and whether the parents were clear how long the medication should be given.

When health service providers fail to counsel poor parents about infant nutrition and the need for immediate treatment for diarrheal dehydration, children’s lives are put at risk ( See Boxes 9 and 10).

Box 9. How to feed my child when breast milk fails?
Parhan was born a healthy 3.5 kilos, the fifth child of his 38 years old mother, Hoiriyah. Parhan is now 20 months old, and underweight, weighing only 6 kilograms. He is often sick, and cannot stand or walk. Hoiriyah stopped producing breast milk seven days after Parhan’s birth. From then, he was fed water only until he was one month, when he was also given boiled rice. His parents have taken him to the bidan desa often to cure diarrhea, for which she gives them ORALIT but no nutritional advice. Parhan’s family still does now know how to feed the baby. Health workers at the nearest health center mentioned that this is a frequent pattern in the region, but they have not devised corrective or preventive approaches. Site Report, Alas Kokon

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Box 10. Diarrheal death of infant - close to services in a mega city
Six month old Keni suffered a bout of sudden diarrea and vomitting. Her parents took her to the nearest Puskesmas , which was understaffed due to a national holiday. Keni waited a long time to be examined, by which time she was severely dehydrated . She was referred to the city hospital. No one told Keni’s parents that delay in getting Keni to the hospital could be fatal. Keni’s father did not have a health card. Afraid that the hospital will cost much money, he delayed taking Keni there. Instead he went home to contact his neighborhood chief (Pak RT) to get a letter certifying that he was poor, which would get him free hospital treatment. By the time he got the letter

Site report, Simokerto, East Java

None of the poor respondents in the study knew about an official Health Ministry provision (Danareksa) by which the bidan desa can provide services to the very poor needing her help in an emergency, and claim reimbursement of her own fees/costs from the Puskesmas. If they had been informed, many of the poor could have been encouraged to contact the bidan desa early; many of the deaths in complicated child births might have been avoided.

4. “Clean” Water Services Used by the Poor
Poor Indonesians do not have access to public water services and buy water at 15 to 33 times the utility’s water tariff.

4. 1. Poor Lack Reasonable Access to Potable Water
In rural areas 40 percent of the poor were using unsafe water sources (unprotected dug wells and rivers) for drinking and cooking (see Figure 3). Another 22 to 25 percent were buying water from vendors whose methods of carting are often unhygienic. In Bajo Pulau, for instance, a vendor transports bore well water from another island in open drums stowed in a boat hull lined with a dirty tarpaulin. In Simokerto water is sold in old, discolored plastic jerry cans.

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Voices Of The Poor

and Keni reached the hospital she was critical. After two days on an intravenous drip, Keni died.

Figure 3. Proportion of votes for choice of Water Services used
Women's view 13% 8% 11% 12% Men's view 8% 14%

10%

32%

11%

Voices Of The Poor

26%

22%

5%

25%

4%

River (no clean water supply) Borewell with pump (neighbor's) Public handpump Protected dugwell

Unprotected dugwell Vendor reselling PDAM water/borewell water Buy PDAM water from neighbor

In urban areas, not a single poor household was connected to utility networks. The poor buy PDAM (District Water Company) water from neighbors who are connected or from vendors and pay 15 to 33 times the rate PDAM charges low-income customers. Because they must go through many middlemen for their water, the poor pay six to eight times more than the most affluent households in Indonesian cities pay.

The poor are typically not aware that they are paying exorbitant rates because they pay small sums for small, incremental amounts of water. Poor people often believe that they cannot afford to connect to piped water supply, which could be true given the connection fees and the fact that they often live far from the network feeders. But the poor are certainly able to afford water consumption at PDAM rates, since they already pay many times more than that rate (see Box 11).

4. 2. Water Use and Health Hazards
Potable water is a precious commodity for the poor, who reserve it for cooking and drinking. Washing and bathing in clean water is a luxury they cannot afford. At all sites, poor people bathe and wash clothes in rivers, at unprotected dug wells or even in seawater.

This has important health implications. The strong cultural preference for defecating in running water has led to an ingrained habit of defecating in natural water bodies. Several participatory evaluations of water and sanitation projects8 and the Baseline Survey for the WSLIC project conducted by the University of Indonesia in 2003 found that: “Almost all people wash their clothes, take a bath and defecate at the river even though they have a well. Defecation in the river is perceived as ‘clean’, as it does not create a bad smell, like defecating in a poorly ventilated toilet.” People also often throw garbage in the river and use the same river to wash their livestock, clothes and motorcycles—as well as themselves.
8 WSP-EAP , 1997, 1999, 2000

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Those who do not wash and bathe in rivers and streams use water from unprotected dug wells without boiling. In the Surabaya slum, water is “reddish, brackish and smells bad”. In Soklat the wells had no cement platforms and were surrounded by muddy, stagnant pools. In Jatibaru, the walls of the dug well are made of old metal drums used for storing industrial chemicals. The wells are located next to stables and have no cement platforms to prevent environmental pollutants from seeping in. Solid waste garbage has blocked existing drains so that wastewater stagnates around wells. Voices Of The Poor
27

In people’s minds, well water is “clean”, while river water is not. Thus, those who are able use well water to wash and bathe consider themselves fortunate, regardless of the condition of the well. Levels of satisfaction with well water tend to be high unless the water is visibly colored, has a bad odor or is brackish. (See Annex 3, Figures 3.14 and 3.15).

Box 11. The poor pay 30 times PDAM tariff for water – but don’t realize it

Perception:
“Pak Ketua RT (the neighborhood head) says we can’t afford a house connection to the PDAM’s piped network because the connection cost Rp. 750,000 ($75) is too high for us. What is more, now that PDAM’s tariffs have increased from Rp. 300 to Rp. 700 per cubic meter, the monthly costs of water consumption will also be unaffordable for us. We spend only Rp. 300 everyday to buy 30 liters for drinking and cooking. We buy it from our wealthier neighbors in buckets, paying Rp.100 for 10 liters” Kalimantan Women’s Focus Group, Antasari, South Kalimantan “We can never hope to get a household water connection from the PDAM. It will cost at least Rp.3 to 5 million, because the pipeline will have to cross a railway line, a highway and a market, to reach Simokerto where we live. Who can afford it? Moreover, we are not owners of this land we live on so we can’t apply for water connection. This land belongs to the State Railway company (Perusahaan Jalan Kereta Api)” Men’s Focus Group, Simokerto, Surabaya

Reality:
The poor in Antasari are paying their neighbors Rp. 100 for 10 liters of PDAM water. This implies a rate of Rp.10,000/cubic meter of water—more than 13 times the PDAM tariffs of Rp. 700/cubic meters. The poor in Simokerto buy re-sold PDAM water from a vendor at Rp.1,400 per day for 50 liters of water delivered to homes (or Rp.700 per day for 50 liters if collected from the vendor’s outlet). This implies a rate of Rp.28,000 per cubic meter of water delivered at home. The current PDAM tariff for household connection in Surabaya is only Rp. 850 per cubic meter

4. 3. The Poorest Pay the Highest Price for Water
Water is costly. The poorest households—which comprised between 51-73 percent of community households at different sites—spend from a low Rp.5,000 (Jatibaru) up to a high Rp.60,000 (Bajo Pulau, Antasari, Simokerto) a month for water (see Table 3). This means that the poor can spend as much as 15 percent of their income for drinking and cooking water (Bajo Pulau).

The costliest water is bought from vendors. The cheapest way for the poor to obtain clean water was to collect it from the mosque or a well off neighbor. In rural areas, this is usually bore well water; the poor pay about Rp.5,000

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

a month to cover electricity costs of pumping it from wells. In the city, poor people collect PDAM water from neighbors’ homes paying them about Rp.30,000 a month. In Soklat and Kertajaya, the poor spend about 30 hours a month collecting dug well water from neighbors’ wells or public wells. Households in Alas Kokon spend 150 to 200 person hours a month hauling water for washing, cleaning and watering animals. Women in that village say it takes them “two to three trips to the river to bring back water from the river, walking 1.5 kilometers each time”. Along with washing and cleaning, “that adds up to more than three hours everyday”. Voices Of The Poor

Table 3. Costs of clean water services and water use by poor household at 8 study sites Rural Sites
Paminggir/S.Kalimantan (River. No access to clean water) Bajopulau/NTB (Bore well water from another island, brought by boat by vendor) • Drink river water, after sedimentation and boiling • • Bathe & wash in the river • • Defecate in the same river • Defecate on the beach • Rp.30,000 + 30 person hours/ month for 35 liters/day Buy water only for cooking & drinking (Rp.30,000/month) Bathe & wash in the sea • • • Quota 20 liters/day/ household,only for cooking & drinking, time cost 8-10 hrs. per person/house/month No payment Collect river water for other purposes, using 210 person hours/house/month • Use simple pit latrines at/ near home • Most also defecate in the same river • • 30 person hours per month & Rp.5,000 for buying cooking & drinking water from mosque Bathe + wash in river Alas Kokon/Madura (protected public dug well) Kertajaya/W.Java (public handpump)

Urban sites
Antasari/S.Kalimantan (buy PDAM water from neighbor) • Rp.30,000/month for 100 liters/day at Rp.100/10 liters, only for cooking & drinking (>13 times the PDAM rate in the small town*) • Bathe + wash in river • Bathe + wash at neighbor’s unprotected well (no cost) • Use unimproved pit latrines at home • Large % defecate in the same river • Most defecate in the river • • • Jatibaru/NTB (buy water from neighbor’s bore well with pump) Rp.5,000/month for sharing electricity cost. Collect about 120 liters bore well water/day for cooking & drinking • Simokerto/E.Java (buy PDAM water from vendor) Rp.42,000/month for 50 liters water delivered home everyday, for drinking and cooking (>30 times the PDAM rate) Bathe + wash at public dug well Defecate in pit latrines at home/by railway line/ into river/public toilets • • Half use sanitary latrines shared with several households Other half defecates in river or pond * Lowest PDAM tariff for house connections in Antasari = Rp. 700/cubic meter water. Lowest PDAM tariff for house connections in Surabaya = Rp. 850/cubic meter of water • Bathe + wash at well • Soklat/W.Java (neighbor’s dug well – unprotected) 30 person hrs./month per household to collect water for cooking and drinking. Boil water for drinking

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4. 4. Observation Results: “Clean” Water Services
It was not within the purview of this study to carry out bacteriological tests of water samples at the sites. Observations included: a) checking for the nature of the water sources used, viz. improved or unimproved sources according to global MDG monitoring definitions9 , b) condition of water sources, and c) possibilities for contamination. Voices Of The Poor
29

By these criteria, the poor at half the sites had no access to clean water. They were drinking and cooking with water from unimproved sources open to various forms of organic and chemical pollution. At the other sites, water from improved sources was available in very limited quantities, due either to the capacity of the source, or the price of water.

The poor pay the highest prices,but get the lowest quality. Because of the high rates
Illustration 5: Urban slum poor buy PDAM water resold several times—each time the price increases. Bulk water seller filling small-scale provider’s jerry cans from PDAM water stored in drum.

of the water vendors, the poor bought water at 15 to 33 times the rate consumers pay to utility companies. Because of the costs, none

of the poor can wash and bathe in clean water. Rivers, lakes, and the sea are used for washing and bathing; clean water is used for a scanty final rinse.

Water vendors are unregulated and monopolistic. They collect water from supposedly clean sources such as utility (PDAM) connections or bore wells. However, water passes from large and medium scale water re-sellers to small scale vendors, who use a variety of unsanitary means (used chemical and oil storage drums, rubber hoses, funnels, etc.) to transport water. There are no regulations requiring regular cleaning and periodic replacement of these containers or equipments.
Illustration 6: Unprotected dug well, lined with an industrial drum, in urban Jatibaru, NTB. Water from this well is used for all purposes. .

Contamination levels of the water finally reaching poor consumers through vendors are likely to be much higher than acceptable norms, but would require a bacteriological examination to confirm.

9

The WHO-UNICEF Joint Monitoring Program classifies improved water sources as protected dug wells, protected springs, tube well/borehole; rainwater collection; public tap/standpipe; piped water into dwelling/yard/plot; and bottled water only when there is a secondary source that is also improved.
Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

The poor consider dug well water to be clean. However, the physical conditions of dug wells and the surrounding environments observed indicated that the water in all save one was and remains highly contaminated. Only Alas Kokon had a protected dug well, but its capacity was limited. Poor users were allocated a quota of only 20 liters per day per household, to be collected and stored once a week. This was used only for cooking and drinking.

Vendors have a vested interest in perpetuating their highly profitable, monopolistic hold on poor clients and have Voices Of The Poor been known to subvert other water supply options. Box 12 presents an example.

Box 12. Held to ransom by monopolistic water service
Bajo Pulau island has only one source of clean water – a private bore well three kilometers from the seaside hamlet of the poor. Because of the hilly terrain, the poor cannot access that source. They survive by buying water for cooking and drinking from the vendor who transports bore well water from another island. He sells the water at Rp.1,000 per 35-liter jerry can ( Rp.28,600 per cubic meter). The better off can buy three to five jerry cans a day. The poor buy one jerry can a day, affording 35 liters for a family of six to eight people. They bathe and wash in the sea, using the precious jerry can water only for a scanty final rinse. The water is transported un-hygienically in the tarpaulin-lined hull of a boat and open drums. It is contaminated with dust and traces of oil. The water vendor’s first priority is to sell water to boats anchored at the port, and serve the poor community only with leftovers. Women often wait up to two hours on the beach for the vendor to come. They can only helplessly curse the vendor if he fails to show up or runs out of water. They suspect that the vendor intentionally damaged a government-built undersea water pipeline. Because the Public Works Department planned and built the pipeline without involving the community, no local organization was established to manage and maintain it and it fell into disrepair. Site Report, Bajo Pulau, NTB

4. 5. Quality of Services: Views of the Poor
Access to clean water is a prime determinant of quality of life. Having to depend on a water vendor’s whims frustrates and angers poor women in Bajo Pulau: “We wait on the beach for the vendor’s boat. Sometimes we wait from the morning and he comes as late as 2 in the afternoon. If his supply is finished serving the big boats in the harbor, we don’t get any. Just wait for the day when he might need our help—then we’ll fix him!”

Urban poor who buy utility-supplied water from vendors or neighbors (albeit at a high premium over the utility rates) are highly satisfied with water quality and price. According to the poor in Simokerto and Antasari: “The PDAM water is clean, has no smell or color, can be used without boiling, does not need to be pulled up (from wells), and is affordable.”
Illustration 7: Water transported in boat’s hull to Bajo Pulau, a rural island off Sumbawa coast, NTB

This comment was surprising, considering the poor were paying many times more than the PDAM rate per

cubic meter of water. It completely debunks the myth often stated by PDAMs that the poor are not profitable customers because “they cannot pay cost-covering tariff rates.”

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

In fact, many of the local poor work as water vendors for the cartels that serve designated slums. These cartels decide the selling price for water and do not allow competition that might bring down prices. There are designated filling stations in each Kelurahan supplied with a PDAM connection; consumers may buy their water at the filling stations or have the vendor deliver it to their homes at twice the cost. Because of the high prices, the poor only buy limited quantities of clean water—just enough for cooking and drinking. They accept as a fact of life having to use unsafe water from polluted wells and surface water sources for all other purposes. Consequently, they had no complaints about unsafe river water when it was available and free. Nonetheless, others recognize the impacts this “free” water has on people’s health. The Mantri
Illustration 8: Water vendor’s boat, Bajo Pulau, NTB

from the health outpost in Paminggir comments: “This village needs a clean water supply more than

any other health service. Each year there are numerous cases of diarrhea and skin diseases because the people use the river for drinking and cooking as well as for all bathing, washing and defecation.”

5. Sanitation Facilities Used by the Poor
Water availability, water use practices, and sanitation practices are intrinsically linked, as amply illustrated in the previous section. Sanitation practices reflect what people consider clean, convenient and comfortable—and what is available. Figure 4 shows that, except for a tiny minority in Soklat (West Java), poor men and women at all eight sites have no access to any kind of “improved sanitation facilities.”10

10

“Improved sanitation facilities” are defined by the WHO-UNICEF Joint Monitoring Program (used for global monitoring of MDG targets) as: ventilated improved pit latrines, pour flush latrines, simple pit latrines with cover, or connections to septic or sewer systems. This definition excludes bucket latrines, open pit latrines, public or shared latrines, and latrines discharging directly into water bodies.

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Voices Of The Poor

Figure 4. Proportion of votes for choice of sanitation facility used
Women's view 4% 14% Men's view

25%

Voices Of The Poor

44%

11%

41%

10%

16%

9%

8%

17%

River (open defecation) Beach (open defecation) Unimproved pit household latrine

Field (open defecation) Unimproved pit away from home Shared household latrine

The coastal Bajo Pulau community defecates on the beach at night or before down, so that the tide can wash away the feces. At six other sites people prefer to defecate in the river, while washing, bathing and brushing their teeth in the same river water (see Table 3). Defecation in the water leaves no visible excreta or obvious smell, and is thus considered “clean” and in fact a “healthier option” than the smelly, simple pit latrines and public toilets available to them—this despite the decades of efforts by health authorities to push the health benefits of latrines.

Women (61 percent) and men (74 percent) said that they defecated in the open in rivers and small streams, beaches, ponds, rice paddies and bushes. The use of natural water bodies is free, whereas there are long lines and a Rp.200 charge at public latrines in the urban Java slum. Unsafe open pit household latrines are used by another 25 to 35 percent. These are no more than holes dug into the yard (Alas Kokon, Jatibaru), directly beneath the home on stilts in swamp areas (in Antasari), or by the railway track embankment in the urban slum (Simokerto).

There are gender differences in sanitation behaviors (see Annex 3, Figures 3.16 and 3.17). Privacy was reported as the most important rationale for sanitation behavior, in conjunction with convenience and “cleanliness” (natural running water). Regardless of the quality of the latrine facility, a household facility is preferred over having to go out for defecation – particularly where homes are not close to the river or the sea (Alas Kokon, Antasari, Soklat, Simokerto). Women prefer the household facility more than men do.

Another major obstacle to poor people gaining access to improved sanitation is the widespread misconception about sanitary latrines being an expensive luxury. The poor are under the impression that latrines cost a lot of money

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(Rp.750,000 – 2,000,000, i.e. $75 – 200), and are therefore out of reach of poor households. In a country where half the people live on less than $2 a day, such perceptions are rational. The misconception is born of poor people having seen only expensive household toilets built by upper class households. Public Works departments have not helped, by promoting only standardized engineering designs of high-cost options certified as “hygienic”.

The poor do not have basic sanitation services. This study found barriers to improving public sanitation to include: 1) public perceptions of open defecation into water bodies being a desirable practice; 2) widespread ignorance of low-cost sanitation alternatives and misconceptions of sanitation being an expensive luxury; 3) lack of mechanisms to effectively promote better sanitation and hygiene practices and low-cost sanitation improvement options.

In both rural and urban areas the poor use any natural water body available as the preferred sites for excreta disposal; some do so even when they have latrines built at home through project- provided funds or subsidies, because of the unpleasant and typically unsanitary conditions of the latrines. The result is a grossly under-recognized environmental disaster that affects the living environment for the total population in Indonesia, both the poor and the non-poor alike.

People use latrines when they are clean and convenient. At a Java peri-urban site, a small group of people had access to sanitary household latrines built by a project. These latrines were reasonably well maintained and shared by four to five households. People were less inclined to use public toilets provided by an NGO, which were grossly inadequate in number, poorly maintained despite a Rp.200 fee per use, and plagued with long queues in the morning.

Apart from these two instances, various forms of unimproved household toilets built by the poor were encountered at half the sites. In the rural areas these were the bamboo poles or wooden slats over ponds or rivers, often temporarily enclosed with fabric or makeshift wooden structures, or simply holes dug in the backyard.

Illustration 9: In Paminggir, rural South Kalimantan, the poor live on the river and use it for everything: cooking, drinking, washing, bathing and defecating (right). Enclosure in the background is a latrine.

In the urban areas these holes were often cemented and incorporated within dwelling units, but they discharged raw feces directly into urban drains or rivers. The poorest in squatter and slum settlements do not have even these holes. They seek out public land with any semblance of privacy for open defecation, or

defecate into urban rivers just as in villages.

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Voices Of The Poor

5. 1. Observation Results: Sanitation Services

Rural primary schools and half the urban primary schools lacked functional sanitation facilities for students. The urban and the secondary schools had functioning toilets for students and teachers, but the ratios of students to toilets were upwards of 100 to 1 at most sites, which Voices Of The Poor would preclude their use by all students.

The government has not dispelled the myth that sanitation is expensive. The reality is that in most parts of inhabited Indonesia today, it is possible to build low-cost sanitary
Illustration 10: Open pit household latrine in a backyard is accessible to domestic animals, further expanding the chances of the spread of diseases. Alas Kokon, Madura

toilets using locally available materials and labor, at costs ranging from Rp.100,000 – 300,000 (US$10 - $30)—within the reach of the majority of the poor. However, there are no programs to raise public awareness of the real costs

and consequences of poor sanitation, and to widely promote low-cost options for sanitation improvements.

5. 2. Quality of Services: Various Views
The quality of sanitation services for the poor is abysmal. There is no visible effort on the part of local or national governments to provide the poor with solutions for this basic need.

In rural areas, natural bodies of water become ad-hoc toilets, imperiling the health of the community. The Pustu paramedic in Paminggir said: “The biggest health problem here is the river, which is the
Illustration 11: Household toilets exist in urban poor neighborhoods they typically discharge directly into rivers or drains behind homes which flow into urban rivers. Simokerto.

principal life support for the villagers…. It’s used for all purposes by the villagers, including bathing, washing, cooking and drinking, as well as excreta and wastewater disposal.

Diarrhea and skin diseases occur frequently; annual floods turn them into epidemics. We can treat diseases with drugs, but we can’t prevent them.”

The lack of basic sanitary services impacts other services such as education. In rural areas, teachers often refuse to stay in the villages—and consequently often don’t show up to teach. The volunteering local teacher at the Paminggir primary school explained that the trained teacher is seldom in the village (even though living quarters are provided) because there are no sanitation facilities. The official teacher goes back to the city “to wash clothes” and is usually late returning to his duties in the village. Local teachers at Bajo Pulau echoed these views.

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There seem to be no norms governing basic water and sanitation facilities in the construction of school buildings. Primary teachers in rural Kertajaya said their school had been built without any water or sanitation facilities. They later received one toilet from the Kecamatan Development Program (KDP)—one toilet for the entire school, which proved inadequate and soon broke down. Voices Of The Poor
35

Similarly, there seem to be no funds set aside in local budgets for routine and regular maintenance. In urban Soklat, after the students’ toilets broke, the teachers
Illustration 12: Natural bodies of water are the preferred places to defecate, as illustrated by this toilet over a pond in peri-urban Soklat, West Java

allocated one of the two teachers’ toilets for the use of female students. Repairs had to wait for the next annual government allocation, many months away.

Public pay toilets are a financial burden for the poor. In the Simokerto slum settlement, the money collector at the public toilet says less than 30 people a day use the toilet, although the neighborhood (RW) has 300 households, many of which are within 100 meters of the toilet. He believes the Rp. 200 charged per use is too much for the poor to afford.

6. Poor Have Little Client Power—But They Want It
The poor are disempowered. At all eight sites, it was clear that the men and women had little concept of their own power or their rights as clients. The top-down approaches of the New Order era and feudal societies have left a heritage of unequal relationships which extends to the relationships between the poor and their service providers.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Box 13. “They give us no choice….”
About 15 years back, all married women in Rancajaya village were forced to accept the spiral (intra-uterine contraceptive device). Women were rounded up by government workers and taken by pick-up trucks to camps for insertion of the spiral. Not a single married woman could escape. Women who hid were chased until found. Those who refused or ran away had their houses marked with red strips for follow up. Many women who received the spiral suffered for months from pain and bleeding. Husbands were scared for the health of their wives and tried many things. Some had their wives spend hours sitting partly submerged in the river or water tanks, hoping that the spiral would float out. Nothing worked.

Voices Of The Poor

All those women and their daughters—now married with children of their own—are so frightened of contraceptives that they avoid using any. “Health workers never give us information about different types of contraceptives and what are the benefits and disadvantages of each type. Don’t be surprised if in the women’s group discussions you find married women who have never seen a condom!” As related to researchers by the men’s group in Kertajaya, West Java

6. 1. Lack of Information-“We Don’t Know”
Typically, the poor have no direct access to information of programs directed at them and so have little or no idea of their rights. The researchers did not find any public material publicizing what services are available (such as Kartu Sehat, Askes and scholarships) or describing how those services could be obtained. Service outlets—Pustu, Puskesmas, schools, and village government offices (Kantor desa/Kelurahan)—simply did not have
Illustration 13: Lost opportunities: In the ANC examination room, Soklat, West Java, posters show diagrams of labor and reproduction system. There is no information for women about danger signs in pregnancy, or protective services available.

supporting literature. Poor women asked: “Why is there no information about these measures on radio and TV, in posters in Puskesmas?” In their own eyes and in the eyes of service

providers, the poor are passive recipients of whatever services and information the service providers or community leaders choose to make available. They must depend upon community leaders (Ketua RT or Kepala Desa) to list them as “poor”, and then depend on Puskesmas workers to dole out the quota of Kartu Sehat/Askes cards, or upon school principals to award scholarships. Typically, poor are also at the mercy of water distributors—when they will deliver and how much they will charge.

Confusion Regarding Pro-poor Services Available
The poor do not know accurately what fees should be charged for pro-poor services—a very central issue in the lives of the poor. Because of the lack of information, none of the poor in the study knew about an official Health Ministry provision (Danareksa) by which the bidan desa is reimbursed for providing emergency services to the very poor. Residents at two sites did not know about health cards. The poor said it was never clear which medicines are free for Kartu Sehat users (Simokarto, Soklat, Jatibaru) and which not.
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At other sites the poor were aware of services such as cheap rice (Raskin) and health card. Information about school fees being waived was well known at six sites, although they understood the school operation funds (BOS) program to start as of September 2005 when in fact the date was July 2005. At Jatibaru (NTB) and Soklat (West Java), the poor said they had found out late, from television. The primary school did not inform parents. In fact, in Soklat, parents paid tuition fees for September 2005 before they learned that fees had been waived. The school has not returned the money. Voices Of The Poor
37

Frequently, the people were confused about what the pro-poor services provide and to whom. For instance, at different study sites quotas of cheap rice available to poor households per month ranged from 3 to 20 kilograms. Many had questions about who was eligible for Kartu Sehat. They complained that few poor families received health cards, while many non-poor did because they were related or close to the village chief (Soklat, Jatibaru, Antasari, Paminggir).

The poor repeatedly said they didn’t know the duties of public sector service providers. This was particularly true in reference to health workers manning the Puskesmas, the Pustu or outreach services.

It is not clear to the poor how decisions are made about services or who makes them. In Soklat, the poor approached the Puskesmas to get Kartu Sehat, but most failed: “Everyone passes us on to someone else—no one gives clear answers.” In Jatibaru, the poor asked the school about their children’s eligibility for scholarships. They were told that recipients were “decided from above”.

6. 2. “Who Will Hear Us?”
What To Do About Bad Service?
Poor men and women are aware that they are often not served well, but don’t know what to do. Complaining to local political leaders or the mass media is alien to most of them; they cannot imagine reaching such people nor do they believe that these elites will pay attention. Residual memories of the harsh tactics of the Soeharto regime stifle most dissent. No one at any of the eight sites has ever seen or heard of a negligent service provider being sanctioned in any way, regardless of the number of complaints. “We can’t even ask why we don’t get proper service, let alone sanctioning anyone. We have no authority or power, even to ask questions,” commented women in Soklat, West Java. The result is resignation: “The service provider has the authority to decide what services we can get,” was a typical response in Jatibaru. Complaints might bring retribution. “If we complain, they will exclude us from distribution of things like Kartu Sehat,” comments another from Simokerto.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Fears About Complaining About Poor Services Abound
The poor are at the bottom of the community hierarchy. On densely populated Java where land is a highly prized asset, the poor often do not own the land they live on, which creates a feeling of insecurity and fear of speaking up. In Jati Baru, people claimed it was embarrassing (tidak enak) to complain about the Bidan and Pustu workers, Voices Of The Poor because they had family and social connections in the community; in Madura, the poor hesitated to go to the village leader because “that will create more problems for us later”.

Some villagers did make attempts: In Kertajaya, West Java, the poor asked the village chief to require the bidan desa to live in the Polindes (birthing clinic) built by the community. In South Kalimantan the villagers lodged formal complaints with the local government (Dinas Pendidikan) about a primary school teacher who failed to show up for classes, despite being given living quarters (Paminggir). None of these efforts yielded any results. “The Bidan lives in the town (Sape)”, noted women in Bajo Pulau. “If we call her she always has many excuses why she can’t come, including even low tide! She won’t even get off the boat lest her feet get wet! But we are afraid to complain – she is related to the Village Secretary, and he is powerful.”

The poor are not afraid of complaining about sanitation services—simply because there are no providers. The poor do complaint about monopolistic water servers (SSIPs) in Bajo Pulau, but the complaints get them nowhere. Urban SSIPs satisfy their customers—the exploitative price of the water is hidden by the fact that it is paid in daily increments.

Community Elites Give Directions
Generally, the poor take directions from the people in charge—teachers, health workers, village leaders—regarding pro-poor services (or the lack of them): “We keep quiet and do what they tell us to do”, said one resident of Soklat. “At most we ask our Ketua RT (neighborhood head) if he can explain.”

Box 14. “Because I am poor, and therefore also stupid”
Pak Yusuf has 13 children and earns a meager living working as a carpenter. Only one of his children has entered junior high; two others did not continue beyond primary school because of school fees and because they could not obtain a pass certificate from the primary school. “I could not pay Rp.55,000 required for each certificate”, Pak Yusuf said, adding that he has pleaded with the school to reduce the rate, to no avail. To get their child admitted to junior high school, Pak Yusuf and his wife offered Rp.20,000 and their only valuable asset—a table fan—as registration fee. He still wonders how to pay another Rp.50,000 for uniform and books. He never tried to obtain a letter from the local government certifying his poverty, which could lead to fee waivers. He said: “I am only a poor man, and therefore also stupid. No one told me about this. I don’t know how to get it although I do want to obtain this letter. My experience so far has always been that no one really wants to help me.” Site report, Soklat, West Java

The Ketua RT is an important bridge between the government processes and structures and the people. In contrast, the village chief, his assistants and the village governance apparatus are often too distant to be relevant to the lives of the poor. The people of Bajo Pulau were particularly vehement about village officials: “The Kepala Desa doesn’t care

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

for us. He never comes to our hamlet, even when someone dies. Just throw him into the sea!”, “That Village Secretary just eats village funds!”, “The Badan Perwakilan Desa (BPD, the village council) is just a formality—has nothing to do with us.”

6. 3. Poor Treatment by Pro-Poor Service Providers and Officials
Voices Of The Poor
39

“We feel like stepchildren in the family. Possibly because we don’t own the land we are living on and not paying land taxes to the village government. We have no right to expect any services from them ….” Poor women’s group, Kertajaya

Many health card users said they had to wait at the Puskesmas until paying customers had been served; at the Pustu they were sometimes simply ignored. Women in Kertajaya and Jatibaru said that the bidan desa would only assist them during childbirth if they had gone to her for ANC services previously.

When they are examined by public health service providers, it is cursory at best; sometimes drugs are given without examination. The poor said that they get the public service provider’s attention only when they pay fees at a private facility.

Residents of Bajo Pulau island have thrown away their Kartu Sehat, since it is too far and too costly to visit the Puskesmas on the mainland.

Box 15. Kartu Sehat users need patience and forbearance
“The doctor who works at the public hospital in Jereng also practices privately outside the hospital. My wife had been examined by him at his private clinic during her pregnancy. At the time of childbirth, because I had no money, I took my pregnant wife to the public hospital in Jereng, which is the nearest hospital that accepts my Kartu Sehat. When we reached the hospital I was asked to fill out forms with information about my wife. Soon after, the doctor who had examined my wife before, arrived and started scolding me because I had not taken her to the private hospital which he had earlier recommended. I said I cannot afford the expenses of the private hospital – but the doctor kept shouting at me and my wife…..” Bapak Sobirin, Kampung Rancajaya, West Java

6. 4. No Voice in Community Decisions and Service Provision
According to both women and men, decisions regarding the use of public funds are made solely by government functionaries together with the formal community leader.

“There has never been a public meeting or forum to inform us about plans for local development or government fund allocations to provide services to our community. If there is a community meeting, the Kelurahan workers do not publicize it.” Poor Men’s Group, Simokerto

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Sometimes, this high-handed approach on the part of officials has forced the poor to act on their own and provide supposedly public services with their own meager savings. “Even though the Ketua RT and community representatives are members of the Badan Perwakilan Desa, we never get to know anything about fund allocation for basic services,” noted the men from Kertajaya. “We have sent formal requests to the village government many times to give us an official electricity connection. Now we are spending our own money on cables to draw power from another kampong.” . Voices Of The Poor

6. 5. Problems with the Participatory Process-“We are Stepchildren”
While poor men feel they have no voice in community decisions in general, and in basic service provision in particular, poor women are even more on the periphery: “Women in the Kelurahan, if involved in any activity, are only from the rich households”, said women in the Antasari Focus Group.

The women from Soklat were even more outspoken, “They never call us for meetings and discussions because they think we are stupid, because we don’t have money, because our efforts/ initiatives are small scale, because we are considered ‘small people’ (poor).”

Despite the fact that Indonesia is one of the world’s largest democracies, these poor citizens do not feel as if they are equal.

This state of affairs distorts the quality of participatory processes and equity in outcomes of development projects aimed at poverty reduction and empowerment of the poor. The following unsolicited comments, made during focus groups about community-driven development projects (considered largely successful in Indonesia) illustrate this point:

“We only came to know about the road-building work after laborers from outside the village were hired to build it, although the road is meant for our community’s use, and the program was for providing wage income to our community.” Poor men’s group, Antasari

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Illustration 14: The poor in places like Jatibaru, West Nusa Tenggara (left), and Paminggir, Kalimantan (below) claim that local elites will only listen to their views through outside facilitators.

“The hand pump was installed entirely by project functionaries, starting from selecting the contractor and laborers until construction. The result is a hand pump near the mosque, where the kepala desa wanted to put it. The water is salty. No one uses it. The pump has broken down within one year of construction.” Poor women’s group, Kertajaya

“We have never received any micro-credit services from the poverty reduction project. Those who did had some business initiative of their own, and are the middle class people. The Badan Kerja Masyarakat (community management team for the project) that decides the recipients is made up of people who are not poor. The poor people only get loan and saving facilities from the private mobile banks that visit the community often.” Poor women’s group, Soklat

Help Us Participate
Poor men and women did articulate that they can gain a voice in community life if outsiders support their efforts. The people of Alas Kokon explained their vision: Essentially, they believe they need facilitators from outside the community who can organize meetings or create a forum for open discussion. These external facilitators must care about the poor and they should have the skills to identify who the poor are in the community.

Residents of Alas Kokon were emphatic about the need for outside intervention: “Through government institutions/ workers, this kind of process facilitation is impossible. … Until now, we have not seen any government institutions that care about the quality of services for the poor or about the aspirations of the poor.”

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Voices Of The Poor

7. Recommendations for Policy and Strategy
Following are a series of recommendations for general and specific policy actions and strategies to improve service delivery to the poor. They are drawn from the specific observations, complaints and assessments made by the poor at all eight sites. Based on personal, real-life experiences, these suggestions offer unique insights into the ways poor Voices Of The Poor women and men poor believe services could be improved and form a complementary list of actions to be used along with findings from the quantitative analysis in the main report, Making Services Work for the Poor in Indonesia.

7. 1. For Basic Services in General
1. Establish procedures that allow the poor to seek and obtain pro-poor services on their own without having to depend on community leaders or service providers for procedures to access.

2. Eliminate poor people’s dependency on service providers and community leaders for information that affects their lives and health, e.g. basic services available, their standards and costs, special provisions for the poor, where and how to get.

3. The paradigm of the poor passively and helplessly waiting to get listed/ certified at the discretion of their formal leaders needs to be reversed. Certifications and classifications of who is poor and who is not should become more participatory and be done through collective assessment methods that make it fully transparent and allow local-specific poverty characteristics to be identified and taken into account.

4. Create coordinated information programs to alert the poor to the services that are available to them and to make them aware of the benefits of these programs. There should also be information programs alerting the poor to danger signs—common situations that can and should be addressed immediately by them to avoid harm.

5. Communicate directly with the poor about all pro-poor services through mass and institutional media. Publicize pro-poor services and how to access them, e.g. through radio, regional newspapers, visual publicity materials at puskesmas, pustus, public hospitals, schools, mosques, banjars, village/kelurahan offices and public transport, information handouts distributed to households through neighborhood heads (Ketua RT), men’s and women’s groups (arisan, PKK) and the like. Set up information kiosks in districts and kecamatans where the poor can go to find out about all pro-poor services available in the region from all public and private sector sources. Publicize the presence of such kiosks.

6. Empower the poor with information on service standards that they should expect from each type of provider, and what action to take when those standards are not met. Publicize these prominently at all relevant public service outlets and make their permanent display mandatory.

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7. Establish mechanisms that make it easy and risk free for consumers to report on the performance of basic service providers in comparison to the expected norms. The Kecamatan Development Program (KDP) in Indonesia has fielded several innovative methods of community reporting on corruption, which could be adapted for this purpose. Develop ways for consumers to assess and report on performance of providers that do not require consumer identities to be revealed, since social familiarity with the provider is often the constraint to reporting on poor performance. Find ways to use the results of these consumer reports and link them directly to providers’ salaries and perks to create incentive for best practices in service. Voices Of The Poor
43

8. Publicize these mechanisms and service standards widely through mass media and at all points of service.

9. Prominently publicize consequences of people’s use of such reporting mechanisms. Poor people will not come forward to report poor service performance without concrete proof that it is worth their while to do so and that it is risk free. Previous experiences have convinced them that seeking accountability is an exercise in futility.

7. 2. For Health Services
All of the above apply to Health Services. The following are additional specific recommendations:

1. Improve the transparency and fairness of procedures to identify the beneficiaries of health cards or health insurance (Kartu Sehat and Askes) using methods suggested in point 3 above.

2. Providing information can save lives. Galvanize the health service provision system to focus more on providing life-saving information to empower the poor. Such information includes: • • Making benefits clear; sometimes the poor fail to use services because they are afraid of the expenses. Pregnancy danger signs that require immediate referral to a health center. The poor should not have to depend on TBAs or other advisers to tell them when to take action. • Comparison of ANC services at the TBA and the Puskesmas/Pustu in terms of life-protecting measures, such as TT immunization, and better family-level preparation for potentially risky childbirths, e.g. counseling families to be financially and logistically prepared for emergency transportation to a health facility during labor when the pregnancy has been identified as a high-risk one. • How to feed and care for infants when breastfeeding fails or during illness. (Information should go beyond simple dispensing of drugs and oral rehydration salts). 3. Publicize measures available for the poor to make trained bidan desa’s services more affordable, e.g. Danareksa, whereby the Puskesmas can reimburse the Bidan for her services to the poor. None of the poor men and women in this study had heard about this.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

7. 3. For Education Services
To improve the quality of primary education in villages, a variety of issues need to be addressed: causes underlying teacher absenteeism and performance; affordability and availability of text books; hidden, additional costs putting education out of the reach of the poor; poor quality of school infrastructure. Voices Of The Poor

1. Teacher absenteeism was consistently reported in rural schools; the cases were closely linked to the absence of basic infrastructure services in the village such as clean water supply, sanitation and, to a lesser extent, electricity. Parents said the teachers mostly hail from urban areas and are unwilling to live in the village when basic facilities are lacking. Clean water and sanitation are important not just for teachers but also for students – for whom learning key hygiene behaviors is not possible in the absence of water supply and sanitation.

2. The Ministry of Education (MOE) should adopt a policy to construct schools only with an assured sustainable supply of clean water and locally appropriate sanitary toilets at a ratio of not more than 50 students per toilet. The school health education unit (UKS) should design programs to promote the use of these facilities and key hygiene practices, such as excreta disposal only in toilets and hand washing with soap after defecation and before eating.

3. The MOE’s construction policies regarding primary schools should be reviewed for anomalies that impair quality education. Currently, many primary schools are built with only two or three classrooms, which means that two or three different grades will always be combined for teaching, resulting in a poor learning experience.

4. Establish ways for parents to monitor and report on teacher absenteeism and performance to authorities who are responsible for the teachers and their salaries. The use of teacher attendance registers maintained by school PTAs and annual assessments of teacher performance by all parents of students by simple secret ballot voting procedures could be linked to teachers’ salaries and increment payments. The Ministry of Education should be more directly involved with parents in monitoring teacher absenteeism and enforcing sanctions.

5. Make textbooks available to all poor students. Some possible solutions: schools could purchase the books and lend them to poor students (if necessary, a small, refundable deposit could be required). If students must purchase books, the school should buy back books at the end of the academic year. Parents also suggested that books cover two consecutive years of education, extending their life and cutting costs.

6. Registration fees at secondary schools deter enrollment of poor students. There seems to be no fixed fees; schools charge whatever they can. It is recommended that the government establish reasonable entry fees and publicize them, e.g. a limit no higher than the equivalent of 4-5 days of the local minimum wages.

7. Schools should be built on public transport routes. Students should be given free or subsidized monthly public

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

transportation passes. Private sector transportation providers should be obliged to offer concessional rates to students if they make use of public sector-provided incentives to promote entrepreneurship, e.g. loans at concessional rates to buy public transport vehicles.

7. 4. For Clean Water and Sanitation Services
Policymakers need to wake up to the fact that the poor are paying exorbitant prices for clean water—as much as 30 times utility rates. None of the 424 poor men and women consulted had piped water connections and so did not benefit from the heavily subsidized utility water that is enjoyed by the non-poor. With no access to public water utilities they are forced to buy water from neighbors or independent providers. The rural poor depend on groundwater, access to which is limited in the dry season. Voices Of The Poor
45

About half the population in Indonesia, both the poor and the non-poor, continue to use water from shallow and deep wells, even when they are connected to utility networks. Typically the well water is not potable in urban areas.

At all eight sites the poor had almost no access to sanitation. The situation is representative of conditions across the nation. In both rural and urban areas of the study people were using the nearest natural water body for defecation purposes. The failure to provide basic sanitation solutions for the millions of the urban and rural poor is creating an environmental disaster that impacts all Indonesians. Policymakers need to open their eyes to this little-recognized public health disaster and deal with its roots.

Recommendations on Ways to Supply Clean Water to the Poor
1. In urban areas, assess the real costs of Small Scale Independent Water Providers (SSIPs) operation against profits they make through use of PDAM water. Set non-negotiable ceilings on the price SSIPs may charge, so all consumers pay the same in the city. SSIPs should not be allowed to enjoy subsidized PDAM rates while charging exploitative rates to the poor.

2. Policies and regulations should help ensure competition among water providers, at least in urban areas where multiplicity of providers is economically feasible. Publicize the ceiling rates to educate consumers and encourage the poor to report violations. PDAMs should recognize the market share of the SSIPs and enter into formal contracts with them for supply at lower-than consumers’ tariff rates, with the understanding that re-selling prices will not exceed PDAM’s tariff rates for direct customers. PDAMs should monitor the rates charged by SSIPs to consumers and sever supplies to SSIPs who charge exploitative rates.

3. Recognize that the urban poor are able and willing to pay fair rates for clean water. Poor customers are not an obstacle to PDAMs charging tariffs that cover costs as well as reasonable profit that can make PDAMs viable.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

The poor already pay the SSIPs a lot more than the actual production costs of PDAMs. The principal obstacles to connecting the poor to PDAM networks, which need to be addressed creatively by service provision policies, are: a) the high, one-time cash cost of connection that the poor typically cannot afford, and b) poor people’s lack of tenurial status in their squatter settlements on public land – which at present does not allow them to seek a legal water supply connection. Voices Of The Poor

4. The rural poor were able to get reasonably clean ground water from protected dug wells or bore wells in Java. Well water was not potable or sufficient on the dry NTB island and in the swampy, riverine Kalimantan village. Indonesia’s varied topographical and geo-hydrological conditions require various types of water supply technologies that are geared to local conditions. A national approach to rural water supply should capitalize on the rural population’s high demand for clean water services, and works with the poor to identify and develop service options that meet local demands using technologies and water management arrangements that can be sustained by the local population.

Recommendations to Improve Sanitation Services for the Poor
1. Scale up the application of approaches for rapid communitywide adoption of improved hygiene practices in rural areas.11 Establish national policy and strategies for rural sanitation programs that will enable scaling up of field-tested best practices consistently across the country.

2. Scale up institutional capacity in local governments for promoting a range of locally appropriate low-cost sanitation options so that sanitation is affordable by all. These could range from improved direct pit dry latrines to more sophisticated offset-pit, composting, pour-flush and water-seal single or twin-pit latrines—all with adaptations for cost-reduction using locally available materials.

3. Develop similar options for poor urban communities. A successful experiment in that direction was fielded through the SANIMAS12 project. The approach is currently being replicated by local governments. But because, local governments and legislators do not yet understand the innovative process aspects of the SANIMAS approach, its community mobilization and capacity building components are currently at a risk of being eroded. Services created without adequate community capacity and ownership buildings are unlikely to be sustained.

4. Overarching the above is a larger problem, i.e. a policy and strategy vacuum with respect to sanitation services. To address this vacuum,

11

An example is the Community-Led Total Sanitation (CLTS) approach propagated through selected large scale RWSS programs, which builds communitywide movements and social pressure for all households to be free of open defecation within short time periods. Field trial results in Lumajang, Sumbawa, Muara Enim, Muaro Jambi, and Sambas districts have been promising. For more information see CLTS–related papers in issues of the PERCIK newsletter on the GOI website: www.ampl.or.id

12

Sanitation by Communities project piloted in seven Indonesian cities during 2001-2003, promoting community-based sanitation solutions for the urban poor.

46

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

•

Urban policymakers must better understand the real costs of inaction and what makes for sustained services as these are both key to progress on the urban sanitation front. Sector analyses studies and formative research into how policymakers and opinion leaders think about sanitation in Indonesia are needed to develop targeted advocacy campaigns to generate public pressure for improved sanitation services, and an enabling environment for sanitation investments that can benefit the poor.

•

Devise innovative ways to catalyze high-level political commitment to improving sanitation services for the urban poor. The ongoing failure to do so has resulted in a widespread urban health and environmental crisis in Indonesia – both for the poor and the non-poor, yet the issue remains invisible and low priority for politicians and leaders. Raising the political profile of the sanitation agenda could include, for instance, cross-sectoral analysis assessing the economic and human development costs to the nation from poor sanitation, linking potable water resources and sanitation management with strategies for poverty reduction and economic growth; organizing high-level regional conferences to periodically compare progress among neighboring countries regarding their commitments to the MDGs for sanitation; raising consumer and voter awareness regarding the impact on the entire population stemming from the absence of basic sanitation services for the poor. Voices Of The Poor
47

5. Equipping primary schools with clean water and basic sanitation facilities is considered one of the most costeffective investments for human development. However, provision of these services needs to be directed by policies for sustained functioning and use, e.g. ratios of toilets to students not exceeding 1:50; mandatory hygiene education curricula to accompany service provision; incentives and sanctions in allocation of operational budgets to schools (BOS) linked to funtionality of school water and sanitation facilities.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Voices Of The Poor

48

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Annex 1: Study Tools
Qualitative Research Sample and Sequence of Tools - Making Services Work for the Poor Study INDICATIVE SEQUENCE AT EACH STUDY SITE Respondents 1 Introductory meeting with community group Mixed gender and age groups, possible presence of community leader/s Welfare Classification Break into gendersegregated groups. Local Livelihoods pattern analysis—Have • both gender groups present results. Compare and consolidate • Research instrument • Introduction of researchers (important— where are they from?) • Explanation of purpose of meeting, • Request for permission to research, • Likely schedule of further discussions in the community. • • Information targeted Voices Of The Poor
1

Description of criteria locally used to describe different levels of well being and poverty Proportion of local community “poor” by local definitions. Pattern of major livelihood activities, by gender. Proportion of average poor hh’s. Income/earnings from various sources.

Use available village/kelurahan map to identify areas where most poor households are clustered (using criteria from Welfare Classification) 2 Men, Women and children met in the course of the walk through the community Transect walk (with copy of map, and Environmental Healthwalk Observation Checklist) to visit clusters of poor households, explain purpose of visit, make appointments for FGDs , observe environmental sanitation conditions/ location of poor households visà-vis public infrastructure facilities and health and education service providers. • • Identification of poor households to contact for setting up FGs Living facilities. environment and

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

3

Focus Groups with men and women from identified “poor”households

FGD: MAPPING SERVICE PROVIDERS

An overall mapping of the service-providing agencies/

a. Venn diagramming for service providers in general (See Guidelines provided)

persons who are important to poor women and men, as well as those irrelevant or less useful

Voices Of The Poor

2 groups by gender, each group with an equal mix of 2 age groups: Young women (15 - 30) Young men (15-30) Older women (>30 – 50) Older men (>30-50)

b. Pocket voting: Mapping of local basic service providers, for the selected Health, Education, Water and Sanitation services. (See Guidelines provided)

to them. Probing of reasons why considered useful/not so.

•

What service options are available?

c. Ranking and scoring of options preferred for H/E/WS services OR

• •

Who is providing? Extent of usage of available options

• For the most used option in each category: d. Benefits and Value for Cost perceptions (See Guidelines provided) •

Perceived costs of different options, in cash/kind/ time/ effort Who in the household decides/chooses each type

e. Rating scales for satisfaction with the most chosen option in each category —- criteria used for judging quality (See Guidelines provided) f. If public services included among those not used or little used, , probe for reasons, perceived value for cost and quality. _____________________________________ •

of service option to use ? Actual expenditures incurred to avail of services- in cash and kind, time and effort (daily/weekly/monthly/one time)

Poor men and women’s • rationale for choice , Perception of value for cost Perception of what constitutes quality service __________________________

FGD: VOICE & CLIENT POWER ISSUES With Discussion guide regarding poor people’s experience, ideas for strengthening accountability of service providers and policymakers to the poor— Possible Case Studies identified for pursuing further.

• •

Poor people’s opinions and experience re.exercising client power, client voice, accountability seeking by the poor.

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Identified poor women /Men for case studies

In-depth individual interviews to explore case studies of failures of basic services, (With reference questions for basic health services failures)

Tracing events leading to • Maternal death/disability from childbirth, • • • • • Stillbirth/neonatal death, Infant death, Voices Of The Poor
3

Under-5 death. Severe child malnutrition Girl/Boy of primary school age never enrolled.

• Observations with checklists/standards for • Puskesmas/ bidan/ dukun/ private doctor’s outlet/service provision session. • Primary school, Junior Secondary school/ class activity. • Inspection of public and household latrines, school sanitation and water facilities, • Inspection of clean water sources, Water storage and transportation facilities/ practices of water vendors, • Water quality testing kit for drinking water in poor homes Selected health/ education/water and sanitation service providers • • • •

Girl/Boy dropped out of primary school Quality of selected types of services provided by each provider/obtained by the poor. Condition of service facilities

Interviews with selected Service providers, Providers’ views re: in each category • Quality of (identified specific) services provided Preferences of the poor. Obstacles to improving services for the poor • What can help the poor obtain better services.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

The following participatory analysis tools13 were used to explore different topics, mostly with men’s and women’s groups separately. Participatory Analysis Tools Welfare Classification* Voices Of The Poor Description Tool to elicit local criteria by which people are classified as poor, rich/ well off or in-between classes. This produced site- specific descriptions of poverty, as well as the means to identify community households with whom to engage in, for further research activities. Activity to locate poor households in relation to other households, infrastructure, and other basic services available in the community.

Social mapping*

Health/environmental transect walk* Using the Social Map and a checklist for environmental observation, researchers walked around the community to assess environmental, health, and sanitation conditions, visit poorest clusters of households, meet poor women and men, and set up appointments for group discussions Venn Diagramming This PRA tool was used to understand the institutions that are important in poor people’s lives as well as those which are not relevant/unimportant to them, and the poor people’s reasons for their assessments This PRA tool was used to rapidly map the major livelihoods –related activities of poor women and men in the community, and the proportion of total incomes derived from the various activities This was used to understand the choices available to the poor at each site with respect to providers for different types of services, and the extent to which they were using each type Graphic scales of standard length were used to elicit people’s satisfaction levels with services. The two ends of the scale represented “No satisfaction at all” and “Full satisfaction,” with mid-points and quarter points also marked. A quantitative participatory tool to obtain people’s assessment of the extent to which their expectations are fulfilled by the services available, and the extent to which they think them to be worth the cost incurred to obtain the services.

Livelihoods analysis

Pocket Voting

Rating scales*

Benefits and Value for Cost*

The sequence of tools was interspersed with focus group discussions covering several other aspects such as the experiences of the poor in exercising voice in community decisions and in seeking accountability from service providers. Site reports were produced by researchers for each site studied, in Indonesian, along with a documentation of the results of each participatory analysis tool. Analysis was a collaborative exercise with most of the field team members. This consolidated report was written based on all of these outputs.

13

Fuller descriptions of the * marked MPA tools can be found in Sustainability Planning and Monitoring : A Guide to Methodology for Participatory Assessment for Community-Driven Development Programs . Mukherjee, Nilanjana and Van wijk, Christine. Water and Sanitation Program, IRC International water and Sanitation Centre and the World Bank. 2003..

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Annex 2: Village Descriptions
Table 2.1. Paminggir—Remote, Forestry-dependent Rural Community, South Kalimantan Well being Indicator Livelihood Rich (Kaya) Own 10 fish ponds and In-between (Sederhana) Fishers with 1 speedboat Poor (Miskin) Wage laborers. No fishponds.. Very simple meals, sometimes quantity not enough. Clothes Home ownership Many clothes, good quality. 20m x 8m size. High Enough for needs, but average quality. Medium quality timber Low quality timber (katol) house. Smaller than 5m x 10m. No livestock. village/Pustu. Between Rp.30,000Rp.100,000/day. Household assets All equipment, color TV 21” or bigger, refrigerator, rice cooker, cupboard, chairs + table of wood. Contribution to Arisan (saving + credit group) Proportion of community households 16% 33% 51% Rp.50,000 / week. Some equipment, TV 14” or smaller. Cook with kerosene, plastic or cane chairs. Rp.2,500-Rp.10,000/ week. Do not join arisan. No TV. Cook with fuelwood, 1 chair. Rp.0-Rp.20,000/day. Few clothes, low quality. Voices Of The Poor
5

2-3 speedboats, successful and 2 fish ponds. traders. Diets Varied foods. Eat meat or fish at every meal. Can eat enough to fill stomach.

quality timber (ulin) house, (Balangiran) house. Size tiled floor. Livestock Health Services used Income 30-40 buffaloes. Specialist doctors or city hospital. Rp.100,000/day. 5-8m x 10m. 2-5 buffaloes.

Health Center (Puskesmas). Traditional healer in

Table 2.2. Bajo Pulau - Island Fishing Community , West Nusa Tenggara Well-being indicator Rich/able (Aha mampu/kaya) Livelihoods and livelihood Trade in lobster, pearls, assets sea cucumber, marine fish, own more than one motorboat. Income More than Rp.1 million/ day. More than Rp.40,000/ day. Rp.10,000/ day. Middle/Sufficient (Cukuplah/Lung satataba) Sea fishers, lobster and pearl fishers with own motor boat. boat. Poor (Singsara/Tidak mampu) Fishers with small sail

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Children’s education Lighting facility Health service provider Voices Of The Poor

High School. Have generator. Specialist doctor in Bima (city on mainland).

Primary – Secondary School. Get connection from owners of generator. Puskesmas or private doctor in Sape (town on mainland). Tiled roof, plywood walls, on 6-12 stilts. Rp.25,000-Rp.40,000. Rp.5,000 (5 jerry cans x 35 liters). 14% 42%

Do not complete primary school. Oil lamp. TBA and traditional healer in village. Bamboo and thatch roofed house, on 6 stilts. Rp.8,000-Rp.9,000. Rp.1,000-Rp.2,000 (1-2 jerry cans x 35 liters). 44%

Asset

Stone-built house, galvanized iron roofing, on 12-20 stilts.

Daily household expenditure Daily expenditure to buy water Proportion of total households

Rp.50,000-Rp.100,000. Rp.10,000 (10 jerry cans x 35 liters).

Table 2.3. Alas Kokon - Rural, Dryland Farming Community, Madura, East Java Well-being indicator House Livelihood Rich (Kaya) Permanent structure, ceramic tile floor. Landowning farmers, Government employees, Fruit traders. Daily income Rp.50,000 ++. Land ownership 2 or more hectares of cropland. Livestock Children education Health Services used 3 or more cows or buffaloes. At the most complete junior high school. Private doctor. 0.5 to 2 hectares of cropland. 1-2 goats. Take care of cattle owned by the rich. A few reach and complete Only primary school. Many junior high school. drop out. healer in village. If having money, go to Puskesmas (cost of transport). Puskesmas and bidan desa. bidan desa or traditional No land owned. If owned, only the land under the house. In-between (Sedang) Simple house, selfconstructed. Laborers, some skilled. Unskilled laborers in construction, agriculture, transport. Poor (Miskin) Thatch house, dirt floor.

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Water Supply

Have own water storage tank. Buy from water truck.

•

Dugwell, collect by turn once/week.

•

Collect dugwell water once/week by queuing up, for cooking + drinking

•

Buy from water truck sometimes

•

Bathe and wash in river.

•

Collect water for other Voices Of The Poor
7

needs from river far away. Many hours/ month used to collect water.

Assets

4-wheel transport, TV, tape recorder, refrigerator, motorbike bought with bank-loan.

Second-hand motorbike, bough on credit.

No means of transport, No TV.

Food

Eat 3 times a day, complete with meat or fish and vegetables.

Simple meals, because market is far. 9% 24%

Eat 2 times a day. Rice with corn or cassava and a little dried, salted fish. 67%

Proportion of community households

Table 2.4. Kertajaya – Irrigated Rice-Farming Rural Community, West Java Well-being indicator House • Rich (Sugih) Permanent structure, ceramic tiled/marble floor, on 0.5 hectare land, iron fencing; • Have own bathroom and sanitary toilet. • • • In-between (Pertengahan) Walls half cement half wood/thatch; Simple bathroom and pit latrine. House on own land + 150m2; Furniture simple, plastic. Crop land ownership Livelihood Up to 70 hectares— stretching to next village. • Own rice huller/ shop/ tractor for renting/ business; • Manage own farmlands. • 1,000m2 – 0.5 hectare only within the village. • Work in government or private sector in Jakarta; Use wage-laborers for farming. • • Agricultural or construction laborers Cart/rickshaw pullers in Jakarta, Bekasi, Pamanukan. • • • • Poor (Ora duwe, melarat, miskin) Bamboo thatch house—leaks during rain; Dirt floor; House built on someone else’s land; Furniture wooden— but- self-made. No land owned.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Transportation Foods eaten daily

Car and motorbike. Bread, milk, beef, chicken.

Motorbike. Soybean cake, eggs sometimes.

Bicycle. Rice, soybean cake, kangkung (leafy vegetable). Many children – all cannot be educated; • Some get primary schooling, some never enrolled.

Children’s education Voices Of The Poor

Can go to college.

Can complete high school. •

Health Services Used

•

To private doctor in Subang (district) or Bandung (province capital);

•

To Puskesmas Mantri or doctor in village or in Pamanukan (nearest town);

•

If minor ailment – get medicine from local shop;

•

If more serious – go to Puskesmas with Kartu Sehat or to Dukun (TBA).

• Livestock

Childbirth in hospital

•

Childbirth with Bidan desa

Many goats – given to poor people to maintain, with sharing agreement for offsprings

Up to 10 goats

Do now own. Take care of goats of the rich.

Proportion of Community households

13%

24%

63%

Table 2.5. Antasari—Urban Kelurahan , South Kalimantan Well-being indicator House Rich (Kaya) Tiled roof, ceramic floor tiles, cement and brick walls. Livelihood Trader, or government Middle (Sederhana) Simpler home, galvanized iron sheet roofing, wooden board walls and floor. Kiosk vendor, or Agricultural wage laborers, construction laborer, fishers. Avoid mixing with the rich, feel embarrassed to. Drink and cook with PDAM water (bought from the rich). Bathe and wash at dugwell or river. employee level 3 or more. government employee level 3 or lower. Mix with Mix only with the rich, their own crowd. Water Supply Drink bottled water. Bathe, wash, cook in water supplied by PDAM connection. Freely mix with both richer and poorer than themselves. Cook with and drink PDAM water (own connection). Wash + bathe in dugwell water. Poor (Miskin) Thatched roof, thin board walls, bamboo or board floor.

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Sanitation

Sanitary toilet—more than 1, built inside house.

Household toilet, but some not sanitary, only one per house.

• •

Public toilet In plastic bags and throw out of house/ into river;

• Clothes and jewelry Household assets Silk, pure gold, Rolex watch 21” or bigger TV, high quality furniture, refrigerator. Food • • Means of transport Proportion of Community households Nutritious always Can eat at restaurants. • • Sometimes nutritious; Can eat at warungs (roadside foodstalls) Car/motorbike 19% Motorbike bought on credit 37% Cotton, clothes. Goldplated jewelry Simple furniture – smaller TV.

No household facility. Voices Of The Poor
9

Ordinary clothes nothing

Eat whatever is available at home Sometimes have bicycle. 44%

Table 2.6. Jatibaru—Urban Poor Kelurahan on the Outskirts of Bima, West Nusa Tenggara Well-being Indicator Livelihoods and Livelihood Assets Income Children Education Rich / Able (Ntau wara) Civil servant, traders in brick/stone, farmers. More than Rp.1,000,000/ month University Middle / Sufficient (Nohi ru’u) Carpenter, horse cart driver, seller/vendor, wage laborers. Approx. Rp.10,000/day not regular High school Traditional healer. Public dugwell, Open defecation in river. Primary school/do not complete primary school Health Service provider Doctor. Water and Sanitation Services Own latrine and dugwell (water source) Traditional healer in village. Public dugwell, Open defecation in river. Poor (Ncoki mori) Wage laborers in agriculture, brick/tile production, collecting and selling wood Approx. Rp.5,000/day.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Asset

• •

own land (1 ha); permanent stone built house with roof tile, ceramic floor;

•

Permanent (6-9 pillars) house, with platform, cheap rooftile, bamboo and brick stone wall;

Platform house (4 pillars), cheap materials, bamboo wall/floor.

• Voices Of The Poor

Owner of cow/goat + chicken (+ 10). •

Owner of goat, chicken and duck;

• Food Pattern 3 times per day, rice, fish, vegetables, fruit. Proportion of Community households 18%

Own land (10 are) salted dried fish, vegetables. 54%

2 times per day. Rice with 2 times per day. Rice with vegetables and small fish (fresh) . 28%

Table 2.7. Simokerto—Urban Low-Income Neighborhood and Squatters’ Settlement, Surabaya, East Java Well-being indicator House Well-off (orang mampu) Permanent structure, ceramic tiled floor, about 9m x 15m, Complete facilities. Water supply All have utility connection Some have utility In-between (sedang) Simpler construction about 5m x 8m. Poor (tidak mampu) Small 3m x 4m area, Temporary structure of ply-boards, tin roof, near rail track. Live in parents’ house. Dugwell water – poor quality. Dries up in summer. Forced to buy expensive water from vendor. Sanitation Ceramic toilet pan, in house sanitary toilet Livelihood Traders, shop owners, Communal toilet. A few have own simple toilet, but not sanitary. Salaried people in public permanent well-paid jobs, or private sector. salaried people. Open defecation in pits on public land owned by Railways corporation. Wage laborers, rickshaw and cart-pullers, motor garage workers, water vendors. Unemployed people. Transportation Own car and motor bike. Own motorbike and cycle. Rickshaw or cart – but not all have. – piped water. Drink, cook connections. Others buy + bathe + wash with clean from vendor. water.

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Income Children’s education Health Services used

Above Rp.2 million/ month High school and college Private hospital or specialist private doctor

Between Rp.300,000 – Rp.350,000/month. Usually just high school. Puskesmas or public hospital.

Less than Rp.200,000/ month. Pass primary school at the most. Traditional medicine Voices Of The Poor
11

sellers (Jamu) or healers. Sometimes go to Puskesmas.

Electronic Goods owned Proportion of community households

21” color TV, VCD player, refrigerator. 6%

14” TV, radio/tape player. 22%

None. 72%

Table 2.8. Soklat—Urban Poor Kelurahan in Subang, West Java Well-being indicator Livelihoods and Livelihood Assets Daily household expenditure Income More than Rp.3-4 million/ month. Can even be Rp.50,000/ day Education University High school – Secondary school. Health Service provider Doctor, private hospital, mid wife in village. House Clean, healthy, large house, 2-3 storeys. Ceramic floor, iron fencing. Health Centre, bidan desa, traditional healer in village. bamboo fence. Primary school only, or do not even complete primary school. Massage, traditional medicine. Buy drugs from local kiosk. floor, roof tiles old, thatch walls. No fence. Do not own the land under the house. Rp.15,000-Rp.20,000/ day. Rich / Able (Benghar) Doctor, civil servant, trader, entrepreneur, own shop, car repair shops. Big income. Enough to live on. Middle / Sufficient (Menegah/Cukup) Entrepreneur, car drivers, teachers, share croppers. Poor (Miskin) Construction labor, farm labor, service in a shop, cart/rickshaw pullers Big expenditure but not enough income. Maximum Rp.10,000/ day.

Clean house, cement floor, Poor quality house. Dirt

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Asset

Own refrigerator, sofa, motor car, TV, luxurious house.

Own TV, radio, bicycle, simple chairs, rickshaw/

•

Old bicycle, small radio, simple kitchen set; Nothing 54%

becak, own latrine, electric • pump for water. 20% 26%

Proportion of Voices Of The Poor Community households

Annex 3
Table 3.1. Choice and Costs of Primary Education Services Reported by the Poor at 8 Sites
SITES Certificate (upon completing school) RURAL PAMINGGIR/ S.Kalimantan (SDN) BAJOPULAU/ NTB (SDN) ALAS KOKON/ Madura (Madrasah Ibtidaiyah) KERTAJAYA/ W.Java 65,000 – 100,000 (SDN) URBAN ANTASARI / S.Kalimantan 7,500 – (SDN) JATIBARU: NTB 5,000 (SDN) SIMOKERTO: E.Java (SDN) 750,000computer + copybooks SOKLAT: W.Java 100,000 (SDN) * Payable in instalments throughout primary school period ** All reported that these fees are not being charged since September 2005 NOTE: 100,00030,000/yr 10,000** 60,000 100,0003 yrs 17,000** + 10,000 for 80,000 3 yrs 65,000 / 20,000 35,000 75,000 / 2,000** 15,000 1,000 30,000 / yr 7,000** -18,000 12,000 1,000 5-10,000** 10,000 140,000 / yr N.M. 60,000 55,000 1,000 7,500 10,000 Enrollment/ Registration/ Construction* Uniforms Tuition (monthly) Books (per year) Shoes/Bag (yearly) Snacks (daily)

• •

SDN – Government- run Primary School Madrasah Ibtidaiyah – Community managed Islamic School

Husband and wife choose the school together at all sites

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Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Figure 3.1. Benefit and value perceptions for primary education services

most used by the poor at 8 study sites: WOMEN's perception
100 97.5 100 90 100 100 92.5 87.5 88 95 91.4 94.3 82.2

65

62.5

50

26

0 PAMINGGIR SD Negeri BAJOPULAU SD Negeri ALASKOKON Madrasah Ibtidaiyah RURAL KERTAJAYA SD Negeri ANTASARI SD Negeri JATIBARU SD Negeri URBAN SIMOKERTO SD Negeri SOKLAT SD Negeri

Value for cost score

most used by the poor at 8 study sites: MEN's perception
100 100 100 100 100 100 100 100 100

86 80 82.5 74 74 63 57.5 80

Score

50

0 PAMINGGIR SD Negeri BAJOPULAU SD Negeri ALASKOKON Madrasah Ibtidaiyah RURAL KERTAJAYA SD Negeri ANTASARI SD Negeri JATIBARU SD Negeri URBAN SIMOKERTO SD Negeri SOKLAT SD Negeri

Value for cost score

Notes: SD Negeri = Government – run Primary School (grades 1 – 6) Madrasah Ibtidaiyah = Religious school, also government – run (grades 1 – 6)

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

13

Voices Of The Poor

80

Score

Figure 3.2. Satisfaction Ratings for Primary Education Providers 50 5 27 Paminggir

80 88

100

0 Bajopulau
Voices Of The Poor

50

60

70

100

0 Alas Kokon

25

50

75

100

0 Kertajaya

50

75

100

0 Antasari

50

100

0 Jatibaru

50

60

100

0 Simokerto

25

50

80

100

0 Soklat

50

75

100

Legends

Women's Rating

Men's Rating

SD Negeri Madrasah Ibtidaiyah Score 0 = No satisfaction at all Score 100 = Full satisfaction

14

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Table 3.2. Costs of secondary school education reported by the poor at 8 study sites
RURAL

BAJO PULAU

No SMP on the island. No children continue. Most boys dropout even from SD to work and earn on boats

KERTAJAYA

Only 3 children from the village go to Junior High school, outside village. They are from the upper class households. The entry fee Rp.1.5 million is an unthinkable

amount for poor households Madrasah Tasanawiyah Government-run SMP Negeri / SLTP / Pesantren *Rp.15,000 / month (Community-enterprise. Only 8 enrolled ) URBAN * Rp.100,000 / year, .but. all students scholarship Uniform 45,000/yr 112,000 /year Uniform 30,000/yr. Tuition Rp.38-42,000/mon. Free now. Books 80,000/yr Uniform 30,000/yr Tuition fees 25,000/mon.Free now. Books 60,000/yr Tuition Rp.15,000/mon.-free now Books/shoes/bag 20,000receive

PAMINGGIR

* free

ALAS KOKON

ANTASARI

JATIBARU

Registration Rp.120,000 +

Construction fee.

SIMOKERTO

Construction fee Rp 600,000

SOKLAT

Construction fee Rp. 400,000

– 600,000

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Madrasah Tasanawiyah – Funded by Dept. of Religious Affairs ; SMP Negeri – Funded by Dept of Education & Culture . In view of the data from Welfare Classification below , Secondary School seems to be a service little used by the poor Welfare Classification data from 8 sites regarding characteristics of local poor in terms of “education of children” : Antasari - “Children’s education” not mentioned among reported characteristics of the poor Jatibaru - “Poor children may enroll in SD (primary school) , often they don’t finish SD (primary school)” Simokerto - “ The poor only pass SD/Madrasah Ibtidaiyah. Don’t attend SMP/SLTP (junior high school)” Soklat - “ The poor can manage only up to SD pass” Paminggir - “Children’s education” not included among reported characteristics of the poor Bajo Pulau - “Children of the poor do not even pass SD” Alas Kokon - just reach SD, not pass, drop out Kertajaya - children not enrolled in school – or only in SD

15

Voices Of The Poor

Figure 3.3 Proportion of votes for provider of secondary school education services
Women's view Men's view 2%

Voices Of The Poor

37%

37%

63%

62%

SMP Negeri

Madrasah Tsanawiyah/ Pesantren

SMP Yayasan (private sector)

16

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Figure 3.4 Benefit and value perceptions for secondary school education services

Secondary School Education Service Providers most used by the poor at 8 study sites: WOMEN's perception
100 93.3 93.3 90 100 92.5 95 91 94 87.5 80 75 66

50

No school

0 PAMINGGIR SMP Negeri BAJOPULAU RURAL ALASKOKON Madrasah Tsanawiyah KERTAJAYA ANTASARI Madrasah Tsanawiyah JATIBARU SMP Negeri URBAN SIMOKERTO SMP Negeri SOKLAT SMP Negeri

No school

e

Value for cost score

Secondary School Education Service Providers most used by the poor at 8 study sites: MEN's perception
100 90 100 93.3 87.5 100 92.5 86.67 74 67.5 62.5 74 68.3

Score

50

0 PAMINGGIR SMP Negeri BAJOPULAU RURAL ALASKOKON Madrasah Tsanawiyah KERTAJAYA ANTASARI Madrasah Tsanawiyah JATIBARU SMP Negeri URBAN SIMOKERTO SMP Negeri SOKLAT SMP Negeri

No school

No school

e

Value for cost score

Notes: SMP Negeri = Government run junior high school (grades 6 – 8 or 7 – 9) Madrasah Tsanawiyah = Religious school, run by government (Department of Religious Affairs), grades 6 – 8)

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

17

Voices Of The Poor

Score

Figure 3.5 Satisfaction ratings for secondary school education providers

2 Paminggir

10

40

50

90

100

Voices Of The Poor

0 Bajopulau

50

100

0 Alas Kokon

25

45

50

75

100

Kertajaya

0

50

100

0 Antasari

10

50

90

100

0 Jatibaru

50

60

100

0 Simokerto

25

50 55

100

0 Soklat Legends SMP Negeri MTSn SMP Yayasan Score 0 = No satisfaction at all Score 100 = Full satisfaction Women's Ratings Men's Ratings

50

75

100

18

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Table 3.3. Choice and Costs of ANC Services Used by the Poor at 8 Study Sites

RURAL SITES Bidan Kampung (TBA) Sando (TBA) Dukun (TBA)

PAMINGGIR / S.Kalimantan

BAJOPULAU / NTB

ALAS KOKON / Madura

KERTAJAYA/ W.Java bidan desa, practicing at home in the evenings

Most used

Rp.3-5,000 / visit

Free or 1kg rice

Rp.5,000/ examination Rp.25,000 (incl.Rp.10,000 for transport) bidan desa • Rp.25,000/ home visit Rp.15,000/ examination 2-5 kg rice Dukun (TBA)

In comparison with other If bidan desa available in PUSTU, bidan desa – then at PUSTU but never available

choice available

Rp.3-5,000/ examination ANTARASARI / S.Kalimantan Puskesmas Rp.3,000/visit Rp.3-5,000 + 1 cup rice • Rp.3,000/visit bidan desa Dukun (TBA) Puskesmas – acc.to Men. women • Sando (TBA) according to JATIBARU / NTB SIMOKERTO / E.Java Pustu/ Puskesmas • SOKLAT / W.Java Puskesmas Rp.12,500 (incl. Rp.10,000 for transport) Rp.11,000 (includes Rp.6,000 for bidan desa practising at home transport) Rp.35,000 (incl. Rp.10,000 for transport) Paraji (TBA)

URBAN SITES

Most used

In comparison with other Bidan Kampung (TBA)

choice available Rp.5,000/ examination Rp.10-15,000 Rp.3,000 Rp.3-5,000

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

NOTE: Women generally choose the ANC service provider. Men are involved in deciding with women if seeking ANC services costs cash more than Rp. 10,000.

19

Voices Of The Poor

Figure 3.6 Benefit and Value Perceptions for ANC Service Providers
ANC service providers most used by the poor at 8 study sites: WOMEN's perception
100
100 100 95 100 93.3 90 100 100 95 100

Voices Of The Poor

72 62.5

74 70

50
46.67

Score

20

0 PAMINGGIR Bidan kampung TBA BAJOPULAU Sando (TBA) RURAL ALASKOKON Dukun beranak TBA KERTAJAYA Bidan Puskesmas ANTASARI Puskesmas JATIBARU Sando TBA SIMOKERTO Bidan Puskesmas URBAN SOKLAT Puskesmas

Value for cost score

most used by the poor at 8 study sites: MEN's perception
100 94 90 83.33 76.67 72.5 70 84 84 82 82 82 94 100 100 100 100

50

Score
0 PAMINGGIR Bidan kampung TBA BAJOPULAU Sando (TBA) RURAL ALASKOKON Dukun beranak TBA KERTAJAYA Bidan Puskesmas ANTASARI Puskesmas JATIBARU Puskesmas SIMOKERTO Bidan Puskesmas URBAN SOKLAT Puskesmas

Value for cost score

Notes: Dukun beranak/paraji/bidan kampung/sando = traditional birth attendant Puskesmas = Primary Health Centre Bidan Puskesmas = trained midwife at Primary Health Centre, government employee

20

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Figure 3.7 Proportion of votes for choice of provider for Childbirth Assistance Services
Women's view Men's view

8%

2% 18%

3%

14%

15% 64% 76%

Sando/Bidan Kampung/Paraji/Dukun Bayi Puskesmas

Bidan desa/Polindes Public hospital

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

21

Voices Of The Poor

Voices Of The Poor

22

Table 3.4. Cost of Childbirth Assistance Services Used by the Poor at 8 Study Sites

RURAL SITES Bidan Kampung (TBA) Sando (TBA) Dukun (TBA) Paraji (TBA)

PAMINGGIR / S.Kalimantan

BAJOPULAU / NTB

ALAS KOKON / Madura

KERTAJAYA/ W.Java

Most used

Rp.25,000 -50,000 + Rice 2kg + Rp.25,000 -50,000 + rice 2kg + 1 Rp.50,000 2 coconuts After 3 days post birth another Rp.20,000, rice+coconut bidan desa bidan desa No other option. coconut.

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Rp.50,000 -100,000 + 20kg rice

Compared to other

bidan desa

available choice Rp.200,000-400,000 needed ANTARASARI / S.Kalimantan Bidan Kampung (TBA) Dukun (TBA) JATIBARU / NTB SIMOKERTO / E.Java bidan desa bidan desa never available when Rp.150,000 -200,000 Rp.300,000 -400,000 + Rp.10,000 for transport SOKLAT / W.Java Paraji (TBA)

URBAN SITES

Most used

Rp.50,000 -200,000 + rice, coconut, sugar bidan desa bidan desa

Rp.10,000 + 1kg rice

Ro.300,000 + Rp.20,000 for transport Dukun (TBA)

Rp.50,000 -100,000 or Rp.50,000 + 5 kg rice bidan desa

Compared to other

available choice Rp.250,000 -500,000 depending on length + complexity of labor Rp.300,000 -400,000 Not used any more Rp.300,000 -400,000

NOTE: According to men, the husband chooses the service provider, for childbirth.

According to women, husband and wife decide together.

Figure 3.8 Satisfaction Ratings for Childbirth Assistance Providers

Paminggir

3

30

50

70

100

0
Bajopulau

10

50

70

90

100
Voices Of The Poor
23

0 Alas Kokon

45

50

75

100

0
Kertajaya

25

50

100

0
Antasari

45

50

75

100

0 Jatibaru

50

100

0 Simokerto

50

100

0 Soklat

50

75

100

Legends
Public hospital Bidan Desa Posyandu TBA Puskesmas

Women's Ratings

Men's Ratings

Score 0 = No satisfaction at all Score 100 = Full satisfaction

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Figure 3.9 Benefit and Value Perceptions for Childbirth Assistance Providers
most used by the poor at 8 study sites: WOMEN's Perception
100 97 100 90 100 100 100 91.67 82 100

98

98

97.5

Voices Of The Poor

75 68.75 68.7

50

54

Score
0 PAMINGGIR Bidan kampung BAJOPULAU Sando (TBA) RURAL ALASKOKON Dukun beranak KERTAJAYA Paraji ANTASARI Bidan kampung JATIBARU Sando (TBA) SIMOKERTO Bidan Puskesmas URBAN SOKLAT Paraji

Value for cost score

most used by the poor at 8 study sites: MEN's perception
100 96.67 85 88 100 100 100 95 90 84 84 76 90 100 100 96.67 100

50

Score
0 PAMINGGIR Bidan kampung BAJOPULAU Sando (TBA) RURAL ALASKOKON Dukun beranak KERTAJAYA Paraji ANTASARI Bidan kampung JATIBARU Puskesmas URBAN SIMOKERTO Puskesmas SOKLAT Paraji

e

Value for cost score

Notes: Dukun beranak/paraji/bidan kampung/sando = traditional birth attendant Puskesmas = Primary Health Centre Bidan desa = trained midwife, resident in village, government employee Bidan Puskesmas = trained midwife at Primary Health Centre, government employee

24

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Figure 3.10 Proportion of votes for provider of Infant Health Care Services (2M – 5Y)
Women's view 2% 4% 9% 7% 8% 23% 3% 17% 17% 36% Men's view 2% 3% 4%

5% 6%

21% 35%

Sando/Bidan Kampung/Paraji/Dukun Bayi Dokter (Private practice) Bidan desa/Polindes Mantri (Paramedic) Posyandu

Sando/Dukun berobat Pustu Puskesmas Public hospital

Figure 3.11 Proportion of votes for provider of Infant Health Care Services (0 - 2M)
Women's view 0.5% Men's view 1% 2% 20% 2% 30% 5% 30% 2%

12%

17% 17%

33%

28%

Sando/Bidan Kampung/Paraji/Dukun Bayi Dokter (Private practice) Bidan desa/Polindes Public hospital

Sando/Dukun berobat Pustu Puskesmas Posyandu

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

25

Voices Of The Poor

Voices Of The Poor

26

Table 3.5. Costs of One-time Use of Curative Care Services Most Used by the Poor for Their Children under Five

RURAL SITES Rp.5,000 (if PUSTU providers not available, as happens frequently) Free (during first 44 days the baby is deemed to belong to the TBA who delivered it) If TBA cannot cure, next choice is Mantri at Rp.20-50,000 Rp.5,000 -10,000

PUSKESMAS

PUSTU

TBA/Traditional Healer

bidan desa

PAMINGGIR S.Kalimantan

BAJOPULAU

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

NTB

ALASKOKON Madura

Rp.15,000 (if not cured then second choice Mantri or Kyai at Rp.25000-50,000) Rp.15,000 + Rp.10,000 for transport Rp.3,000 Rp.3,000 + Rp.3,000 for transport Rp.5,000 + Rp.6,000 for transport Rp.2,500 (if this does not cure then next to Bidan- at Rp.25-30,000. If Bidan can’t help then private doctor at Rp.40-70,000 + cost of medicines)

KERTAJAYA W.Java

URBAN SITES

ANTASARI S.Kalimantan

JATIBARU / NTB

SIMOKERTO E.Java

SOKLAT

W.Java

Figure 3.12 Benefit and Value Perceptions for Curative Services for Infants (0-2 months)
Met and Value for Cost for Infant (0 - 2 months old) Health Care Service Providers most used by the poor at 8 study sites
100 92.5 90 85 76.67 64 50 66 60 50 85 76 72 100 94 92.5 90

96.67

Score

0 PAMINGGIR Puskesmas pembantu BAJOPULAU Sando RURAL ALASKOKON Bidan desa KERTAJAYA Bidan Puskesmas ANTASARI Puskesmas JATIBARU Puskesmas URBAN SIMOKERTO Puskesmas pembantu SOKLAT Puskesmas

Value for cost score

Infant (0 - 2 months old) Health Care Service Providers most used by the poor at 8 study sites
100 90 80 70 100 100 92.5 90 90 84 84 100 100 94 100 92.5 100

50

Score

0 PAMINGGIR Puskesmas pembantu BAJOPULAU Sando RURAL ALASKOKON Bidan desa KERTAJAYA Puskesmas ANTASARI Puskesmas JATIBARU Puskesmas URBAN SIMOKERTO Puskesmas pembantu SOKLAT Puskesmas

Value for cost score

Notes: Pustu (Puskesmas pembantu) = Sub-primary Health Centre (outreach facility) Puskesmas = Primary Health Centre Bidan desa = trained midwife, resident in village, government employee Bidan Puskesmas = trained midwife at Primary Health Centre, government employee Sando = Traditional healer

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

27

Voices Of The Poor

Figure 3.13 Satisfaction Ratings for Curative Care Providers for Infants (0-2 months)
Paminggir

0
Bajo Pulau

Voices Of The Poor

Alas Kokon

0

0
Kertajaya

Antasari

0

Jatibaru

0

10

Simokerto

0

0
Soklat

Legends Public hospital Bidan Desa Posyandu Pustu TBA Puskesmas Private doctor Mantri Trad. healer

Women’s Rating

Men’s Rating

Score 0 = No satisfaction at all Score 100 = Full satisfaction

28

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Figure 3.14 Benefit and Value Perceptions for Water Supply Option Used
Met and Value for Cost for Water Services most used by the poor at 8 study sites
100 100 96.67 93.3 90 85 78 90 85 100 100 100 100 92 93.3 100

63.3

50

Score

0 PAMINGGIR River BAJOPULAU Vendor from other island RURAL ALASKOKON Protected public dugwell KERTAJAYA Public handpump ANTASARI Buy PDAM water from neighbor JATIBARU Unprotected dugwell URBAN SIMOKERTO Vendor reselling PDAM water SOKLAT Unprotected public dugwell

Value for cost score

xpectation Met and Value for Cost for Water Services most used by the poor at 8 study sites
100 93.3 90 90 83 86 81.67 100 100 100 100 100 100 93.3 91.67 100 100

50

Score

0 PAMINGGIR River BAJOPULAU Vendor from other island RURAL ALASKOKON Protected public dugwell KERTAJAYA Public handpump ANTASARI Buy PDAM water from neighbor JATIBARU Unprotected dugwell URBAN SIMOKERTO Vendor reselling PDAM water SOKLAT Unprotected public dugwell

Value for cost score

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

29

Voices Of The Poor

Figure 3.15 Satisfaction ratings for water supply options
0
Paminggir

63

90 1

00

0

100

Voices Of The Poor

Bajo Pulou

0
Alas Kokon

25

50

60

100

0
Kertajaya

10

40

50

100

0
Antasari

30

50

80

100

0
Jatibaru

100

0
Simokerto

50

75

100

0
Soklat

50

85

100

Legend River Dug welll Dugwell with pump (sanyo) Borewell with pump (sanyo) Hand pump Utility water resold by neighbor Vendor-sold PDAM / borewell water

Women’s Rating

Men’s Rating Score 0 = No satisfaction at all Score 100 = Full satisfaction

30

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

Figure 3.16 Benefit and value perceptions for sanitation facilities

Met and Value for Cost for Sanitation Facility (Latrine) most used by the poor at 8 study sites
100 100 96.5 90 83.3 80 76 70 93.5 88 100 100 100

56.67 50 48

Score

0 PAMINGGIR River (open defecation) BAJOPULAU Beach (open defecation) ALASKOKON Unimproved dry pit household latrine RURAL KERTAJAYA River (open defecation) ANTASARI Unimproved dry pit household latrine (drop) JATIBARU River (open defecation) URBAN SIMOKERTO Field (open defecation) SOKLAT Shared household latrine

Value for cost score

Sanitation Facility (Latrine) most used by the poor at 8 study sites
100 92.5 94 90 88 76 70 100 100 100 100 100 100

50 44

Score

36

0 PAMINGGIR River (open defecation) BAJOPULAU Beach (open defecation) ALASKOKON Unimproved dry pit household latrine RURAL KERTAJAYA River (open defecation) ANTASARI Unimproved dry pit household latrine (drop) JATIBARU River (open defecation) URBAN SIMOKERTO Field (open defecation) SOKLAT Shared household latrine

Value for cost score

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites

31

Voices Of The Poor

Figure 3.17 Satisfaction ratings for sanitation facilities
0
Paminggir

80

90

100

0

Voices Of The Poor

100

Bajo Pulou

0
Alas Kokon

25

50

100

0
Kertajaya

5

25

100

0
Antasari

10

25

45 50

100

0
Jatibaru

50

75

100

Simokerto

0

25

50

75

100

0
Soklat

30

50

75

85

100

Legend Shared household latrine Public toilet Open pit latrine at home Open defecation in backyard River/sea Pond

Women’s Rating

Men’s Rating Score 0 = No satisfaction at all Score 100 = Full satisfaction

Simple pits, away from home

32

Making Services Work for the Poor in Indonesia A Qualitative Consultation with the Poor at Eight Sites