Berdasarkan data kesehatan selama tiga tahun terakhir sejak diluncurkan program Desa dan Kelurahan Siaga Aktif tahun 2006 tersebut dalam Data Profil Kesehatan baik tingkat Kabupaten, Provinsi, dan Pusat, maka tidak ada data maupun grafik yang menyebutkan adanya jumlah atau cakupan program Desa dan Kelurahan Siaga Aktif. Contoh program kerja satuan olongan siaga PROGRAM KERJA SATUAN. GOLONGAN SIAGA. BULAN JULI S/D DESEMBER. Memberikan pemahaman kepada pramuka siaga tentang dua janji pramuka serta mempraktikkannya dalam kehidupan sehari-hari.
Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine ß The Author 2013; all rights reserved. Advance Access publication 6 May 2013
Health Policy and Planning 2014;29:409–420 doi:10.1093/heapol/czt027
‘Desa SIAGA’, the ‘Alert Village’: the evolution of an iconic brand in Indonesian public health strategies Peter S Hill,1* Lieve Goeman,2 Rahmi Sofiarini3,4 and Maddi M Djara4 1
Australian Centre for International and Tropical Health, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia, Sector and Thematic Expertise, Belgian Development Agency, Hoogstraat 147, 1000 Brussels, Belgium, 3USAID—IMACS Project Chemonics International, Jl. Bung Hatta No. 19, Mataram 83121, Indonesia and 4Consolidation Programme Health/Policy Analysis and Formulation in the Health Sector (PAF), Deutsche Gesellschaft fu ¨ r International Zusammenarbeit (GIZ) GmbH, Mataram 83121, Indonesia 2
*Corresponding author. Australian Centre for International and Tropical Health, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia. E-mail: [email protected]
Accepted
8 April 2013 In 1999, the Ministry of Women’s Empowerment in Indonesia worked with advertisers in Jakarta and international technical advisors to develop the concept of ‘Suami SIAGA’, the ‘Alert Husband’, confronting Indonesian males with their responsibilities to be aware of their wives’ needs and ensure early access if needed to trained obstetrics care. The model was rapidly expanded to apply to the ‘Desa SIAGA’, the ‘Alert Village’, with communities assuming the responsibility for awareness of the risks of pregnancy and childbirth, and supporting registered pregnant mothers with funding and transportation for emergency obstetric assistance, and identified blood donors. Based on the participant observation, interviews and documentary analysis, this article uses a systems perspective to trace the evolution of that iconic ‘brand’ as new national and international actors further developed the concept and its application in provincial and national programmes. In 2010, it underwent a further transformation to become ‘Desa Siaga Aktif’, a national programme with responsibilities expanded to include the provision of basic health services at village level, and the surveillance of communicable disease, monitoring of lifestyle activities and disaster preparedness, in addition to the management of obstetric emergencies. By tracking the use of this single ‘brand’, the study provides insights into the complex adaptive system of policy and programme development with its rich interactions between multiple international, national, provincial and sectoral stakeholders, the unpredictable responses to feedback from these actors and their activities and the resultant emergence of new policy elements, new programmes and new levels of operation within the system.
Keywords
Indonesia, Desa SIAGA, branding, entertainment-education, safe motherhood, community empowerment, policy analysis
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KEY MESSAGES 0002
Branding in public health interventions has the potential to provide high level of message recognition.
0002
Systems thinking provides a policy perspective across the system as a whole rather than within narrow disciplinary or programmatic frames.
0002
‘Desa SIAGA’, the ‘Alert Village’ has developed community awareness and strategies for responding to complications of pregnancy in Indonesia.
0002
The redeployment of the brand ‘Desa SIAGA’ in different disciplinary and programmatic areas has changed its connotations and risks confusion, eroding brand value.
In October 2010, the Ministry of Health (MoH) of the Republic of Indonesia issued a new decree providing general guidelines on the development of ‘Desa Siaga Aktif’, a programme designed to promote ‘Active Alert Villages’. These were defined as villages capable of providing basic health care services and safe water and basic sanitation services, undertaking community-based disease surveillance, encouraging healthy lifestyles and using community empowerment to respond to health emergencies and natural disasters (MoH 2010). The MoH has set itself a target of 80% of its current 75 410 villages achieving ‘Desa Siaga Aktif’ status by 2015 (MoH 2010). The decree reflects more than a decade of evolution of the concept of ‘siaga’—‘alert’, emerging originally from an information, education and communication campaign targeting husbands’ roles in safe motherhood (Shefner-Rogers and Sood 2004), and redefined and repackaged progressively until this most recent expression as a national mandate for village community mobilization. This article explores the evolution of this highly charged creative concept ‘siaga’ in health programmes in Indonesia, beginning with its original use and tracking its subsequent iterations. It examines the changes in organizational ‘ownership’ of the concept, and its application across a number of programme frameworks: initially as multimedia ‘entertainment-education’ health promotion, focusing on the husband’s (then community’s) responsibility for safe delivery; subsequently through ‘demand’ side community mobilization for safe motherhood, with an emphasis on community empowerment and currently in its application as a ‘top-down’ decentralized strategy shifting responsibility for ensuring basic health care, disease and lifestyle surveillance and disaster preparedness to local communities. Table 1 summarizes the key developments. In this context of changing programmes and disciplines in a dynamic policy environment, the concept ‘siaga’ has evolved as a ‘brand’. The process of branding reduces and synthesizes a complex of processes into a single, richly charged signifier that communicates the sense of the whole (Ogden et al. 2003; Walt et al. 2004; Basu and Wong 2009). This analysis explores the ways in which ‘siaga’ is employed as a brand across these diverse transitions, and questions the extent to which it can retain its function and rich connotations through these processes of change. The analysis uses systems thinking as its theoretical approach, and locates this within current explorations in policy analysis that frame health systems as complex adaptive systems (Sterman 2006; Walt et al. 2008; Hill 2011). Systems thinking is . . . an approach to problem solving that appreciates the very nature of complex systems as dynamic, constantly
changing, governed by history and by feedback, where the role and influence of stakeholders and context is critical, and where new policies and actions (of different stakeholders) often generate counterintuitive and unpredictable effects. (Adam and de Savigny 2012) By tracking the use of this single brand across changing agencies, government ministries, departments and programmes, the study provides insights into the complex adaptive system of policy and programme development (Cilliers 1998; Gatrell 2005; Adam and de Savigny 2012) with its rich interactions between multiple international, national, provincial and sectoral stakeholders, the unpredictable responses to feedback from these actors and their activities and the resultant emergence of new policy elements, new programmes and new levels of operation within the system.
‘Siaga’: alert The specific, technical use of ‘siaga’ in health promotion appears first in the ‘Suami SIAGA’ campaign in 1999, a ‘multimedia entertainment-education intervention’ in Indonesia. This programme targeted husbands with messages about their responsibilities around birth, and subsequently trained midwives and community leaders in strategies for prevention of maternal mortality (Shefner-Rogers and Sood 2004). The Ministry for the Role of Women—now the Ministry of Women’s Empowerment—worked with Indonesian advertisers and technical advisors from the Johns Hopkins University Centre for Communication Programs to develop the campaign’s creative concept ‘Suami SIAGA’, ‘Alert Husband’. Substantial qualitative formative research was used to develop and test the concept, which was then integrated into a wave of multimedia strategies: print-based communication, and national television and radio broadcasts. ‘Suami SIAGA’ messages were integrated into radio drama series and a three episode entertainment-education television mini-series broadcast between February 1999 and August 2000 (Shefner-Rogers and Sood 2004). Impact evaluation of the campaign, conducted 10 months into the project demonstrated high levels of knowledge of the key messages, including the need to accompany their wives to antenatal check-ups (89%) and delivery (88%), to recognize danger signs in pregnancy (83%) and to ensure adequate post-natal care (85%). Some 44% of husbands interviewed characterized this as new knowledge; 56% had already communicated their commitment to take action as
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Table 1 Chronological development of Desa SIAGA concepts Programme/Project
Agencies
Year
SIAGA concept
Coverage/content
MNH Project Location: National Media Campaign with focus on East Java, South Sulawesi and South Sumatra
Ministry of Role of Women, Family Planning Coordination Board, JHU/CCP, Program for Appropriate Technology in Health, USAID
1999–2004
MNH Project
Safe motherhood
February 1999– August 2000
Suami SIAGA
‘Alert husband’ aware of possible complications, arranges transport and funds prior to childbirth, ensures antenatal care for wife and delivery in a health facility
November 2001
Warga SIAGA
Ready citizens to assist with identifying risk, providing transport, funds and blood donors
2002–04
Bidan SIAGA
Ready midwife, media promotion, with training activities and radio vignettes
2002–04
Desa SIAGA
Alert village, collaborating in providing: (1) (2) (3) (4)
IFHFW Project Location: NTT and NTB provinces
AusAID and Provincial Health Office, NTT and NTB
2000–06
Identification of pregnant women Coordination of transport Blood donors Funds for treatment
Dai SIAGA
Alert religious leaders should raise community awareness and support values of Desa SIAGA
Wartewan SIAGA
Alert journalists should raise awareness in communities of maternal mortality and community action to prevent deaths
Pesantren SIAGA
Alert Islamic institutions/boarding schools should teach awareness and support for pregnant women
Desa SIAGA
AusAID takes over concept from USAID: same term, same target group: the community Same content: MNH but adding one component (1) (2) (3) (4) (5)
Identification of pregnant women Transport Blood Fund Family Planning info Post
Other implementation partners. Making Pregnancy Safer Location: National
MoH
2000–06
Directorate of Maternal and Child Health; Director-General of Community Health
2005
GTZ, cofunded by DfID, with Provincial Health Office, NTT and NTB.
SIAP ANTAR JAGA
Nationwide Demand-side approach four components: (1) (2) (3) (4)
2006
SISKES, Desa SIAGA Project Location: NTT and NTB
Extension of coverage of antenatal care, delivery and post-partum care; skilled birth attendance; family planning; capacity building and equipping of health facilities; improved referral systems.
2006–09
Identification of pregnant women Transport Blood Fund
Kit developed and SIAP ANTAR JAGA officially part of the national Making Pregnancy Safer strategy
Foreword (¼endorsement) by DG Community Health
P4K ‘Birth planning and complication readinesswith sticker’
Change to supply side strategy to avoid confusion over two DESA SIAGA programmes
Desa SIAGA
Extension of AusAID funded DESA SIAGA project with five components including family planning. Emphasis on community empowerment with development of resources for training of village participants in conjunction with PHO
In 2008: split of MCH directorate into separate Maternal Health and Child Health directorates.
(continued)
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Table 1 Continued Programme/Project
Agencies
Year
SIAGA concept
Coverage/content
DESA SIAGA Comprehensive Location: National
MoH, Health Promotion Unit
2006 Decree MoH
DESI or DESA SIAGA Comprehensive
Based on success of Central Java (Polindes-based community activities) and SIAP ANTAR JAGA Expansion of Desa Siaga: now for all villagers and all health problems: outbreaks, growth monitoring, disaster, drug shops, health emergencies. Result 2009: 56% of all villages is considered a DESI. Indicator is having a POSKESDES. Target: All villages DESA SEHAT in 2010
Minimal Service Standards Location: National
MoH
2008
Desa Siaga Aktif
Target 80% of all villages Desa Siaga Aktif by 2014. Criteria for Desa Siaga Aktif are not defined
Desa Siaga Aktif Location: National
MoH, Health Promotion Unit
2010 Decree MoH
Desa Siaga Aktif
Formalization of Desa Siaga Aktif to revitalize DESA SIAGA DESI. Extensive mechanism with eight targets, four levels of activity to measure ‘activeness’ of the village. SIAP ANTAR JAGA and DS DESI discontinued
exposure to the campaign on knowledge of community based life saving schemes’ (Sood et al. 2004a). The word ‘siaga’ means alert in Bahasa Indonesia—Indonesia’s ‘lingua franca’—but, in a semantic shift common to Bahasa, ‘SIAGA’ (capitalized in its technical use) has been unpacked as an acronym comprising elements of three separate words: ‘SIap, Antar, jaGA’. Put literally, ‘siap’ means ‘ready’, ‘antar’ ‘to take, to transport’ and ‘jaga’ ‘to guard’. But for the purposes of the ‘Suami SIAGA’ campaign, ‘siap’ was redefined as connoting husbands’ alertness to their wives’ needs in any unexpected emergency; ‘antar’, preparedness in terms of available transportation and preidentified blood donors and ‘jaga’, being present and vigilant against the risks of pregnancy, and during and after delivery (Figure 1) (Shefner-Rogers and Sood 2004). This semantic shift is common in both the formal rhetoric of Bahasa Indonesia, and in vernacular speech. Indonesia’s first president, Sukarno used similar wordplay in his political oratory (Keane 1997). Acronyms in formal, bureaucratic contexts are ubiquitous. Acronyms and neologisms also occur in more common usage, and may incorporate elements from local languages from within Indonesia’s multilingual archipelago, or international languages: English or less commonly, Dutch. Intellectualized language play is socially valued (Keane 1997), as is more mischievous language play: the acronym ‘Puskesmas’, or ‘Public Health Centre’ has been constructed from ‘PUSat KESehatan MASyarakat’, but critics of the quality of service its offers may tauntingly reconstruct its derivation as ‘PUSing KESeleo MASuk angin’: ‘nauseous, sprained, feverish’ (Chambert-Loir and Collins 1984).
Methods Figure 1 Siap Antar Jaga poster.
‘Suami SIAGA’ (Shefner-Rogers and Sood 2004). In 2004, evaluation of the impact of the ‘Desa SIAGA’ programme on married women showed increased awareness of the danger signs for pregnancy, with a ‘strong dose–response effect of
The research is a retrospective case study (Yin 2003), examining the evolving use of the concept SIAGA in Indonesia. This article uses qualitative methods as advocated by Reniscow and Page (2008) and Adam and de Savigny (2012) to explore the complex non-linear variables that have influenced policy and programmatic change in this complex policy environment.
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It brings together documentary and policy analysis with key informant interviews, and triangulates the findings from these sources with direct participation in the Indonesian Women’s Health and Family Welfare (IWHFW) Project (2000–06) and participation in the SISKES (Strengthening District Health Systems) project and its evaluation (Sofiarini 2007; Fachry and Sofiarini 2009; Birdsall and Hill 2011; Goeman et al. 2011). Key informant interviews included the Head of the Health Promotion Centre, and the Head of the Sub-Directorate of Delivery and Post-partum in the Directorate of Maternal Health and their senior staff, in the MoH Jakarta, and central and provincial health officials previously involved in ‘Desa SIAGA’ programmes. Site visits in Nusa Tenggara Barat (NTB) allowed observation of ‘Desa Siap Antar Jaga’ (DSAJ) activities in Bima, Banyu Malek and Penanae, and interviews with Provincial and District Health Officers, and with Village ‘Desa SIAGA’ Committees and trainers, facilitators and coordinators. The development of the analysis has been undertaken iteratively. The chronology of the development of ‘SIAGA’ was mapped from previous participation and key informant interviews, and a comprehensive literature search for the search term ‘SIAGA’ using PubMED, Medline Ovid and Google, Google scholar provided additional data. Emergent key themes were used to organize the findings within a framework of critical discourse analysis (Rogers et al. 2005; Carey and Gelaude 2008; Corbin and Strauss 2008, pp. 162–3): brand identification; changes in brand communication and management; national, local and international actors in health; relationships between the state, community and individuals and understandings of risk and response.
The initial context: safe motherhood in Indonesia (1988–99) In 1987, the Safe Motherhood Conference in Nairobi launched the international Safe Motherhood Initiative, calling for a reduction of maternal mortality by one half by 2000 (World Bank 2011). The following year, Indonesia launched its own Safe Motherhood Initiative (Geefhuysen 1999), aiming to reduce the country’s maternal mortality ratio (MMR) from 450 to 340 per 100 000 live births by 1993. But the release of an estimate of MMR of 390 for the period 1990–94 from the Indonesian Demographic and Health Survey 1994 (BPS and ORC Macro 1994) was well above the anticipated level, and caused significant political concern, particularly given the concerted investment in the training and distribution of village midwives (‘bidan di desa’) (Shiffman 2003). The 1995 Beijing Conference on Women provided an impetus for further action, and the following year, the Ministry for the Role of Women, galvanized by Assistant Minister Abdullah Cholil, consolidated their commitment to renewing safe motherhood activities under the banner of ‘Gerakan Sayang Ibu’—the Movement to Cherish Mothers (Geefhuysen 1999; Shiffman 2003). In 1998, the Ministry for the Role of Women partnered with the UNFPA and the Johns Hopkins University Centre for Communication Programs to trial the ‘Suami SIAGA’ project (JHUCCP 2004).
Maternal and Newborn Health Project (1999–2004): the SIAGA campaign The multi-partnered Maternal and Newborn Health (MNH) Project built on a decade of Indonesian government attention to
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the issues of safe motherhood. The media campaigns had national coverage, but focused on three high priority provinces: East Java, South Sulawesi and South Sumatra (Shefner-Rogers and Sood 2004). Formative research for the campaign had confirmed the common perception that pregnancy and delivery were in the woman’s domain, ‘a woman’s secret’ (Shefner-Rogers and Sood 2004). But recognizing that at critical points during pregnancy and childbirth decision making may pass from the pregnant woman to her husband, ‘important gatekeepers of maternal healthcare’ (Thaddeus and Maine 1994; Sciortino 1998), the campaign focused primarily on males of reproductive age, promoting behaviours for husbands that would reduce delays in seeking obstetric care, accessing appropriate services and receiving necessary interventions—particularly emergency obstetric care. In 2000, the MoH now released its Making Pregnancy Safer strategy, based on the WHO initiative (WHO 2000; Mize 2003). The strategy targeted ‘supply side’ issues through improving coverage and quality of health services, personnel and referral networks; and ‘demand side’ issues with a health promotion framework that sought to empower ‘women, men, families and communities’ as partners for improving MNH (Portela and Santarelli 2003). Based on the success of the initial ‘Suami SIAGA’ evaluations, the ‘SIAGA’ campaign was extended to embrace the whole ‘Desa SIAGA’ as an alert village, and the role of the alert midwife, the ‘Bidan SIAGA’, became more central. There had been a conscious programme shift from ‘entertainment-education’ to community mobilization: whole communities were now encouraged to formalize systems that would provide notification of pregnant women, coordinate transport, collect funding and develop blood donation registers that would ensure safe motherhood (Titaley et al. 2010). Coordination was managed through the Provincial and District Health Offices, with 55 ‘Desa SIAGA’ created in areas supported by the MNH Project (JHUCCP 2004). The MNH Project now integrated ‘Warga SIAGA’ (alert citizens) into the structure of the ‘Desa SIAGA’, reinforcing the ‘gotong royong’ community self-help focus of the campaign (MNH 2004). Endorsement from local Islamic religious leaders was sought, and readings from the Koran were included in the media campaigns (JHUCCP 2004). ‘Dai SIAGA’, alert religious leaders, were now encouraged to promote the values of the ‘Desa SIAGA’, offering solace in the case of maternal or neonatal death, but promoting their prevention. Their religious boarding schools were to become ‘Pesantren SIAGA’, supporting community initiatives to protect pregnant mothers. ‘Wartawan SIAGA’—alert journalists—were asked to report deaths and also to promote the ‘Desa SIAGA’ strategies that could prevent them. Media campaigns positioned the ‘Bidan SIAGA’—the alert midwife—as the preferred obstetric provider, inferring their technical superiority over traditional birth attendants, with calendars featuring an attractive young woman and the slogan: ‘Ayo ke bidan siaga’ (‘Come on, let’s go to the alert midwife’) (Devries 2004). The ‘Bidan SIAGA’ training was developed using birth preparedness/complication readiness (BP/CR) frameworks ‘recognising danger signs and preparing for childbirth by saving funds, arranging for transportation to a health facility if necessary, and identifying a skilled provider and birthing place’ (JHUCCP 2004), and sat very comfortably with the MoH’s Making Pregnancy Safer strategy. The ‘Kartu Amanat Persalinan’ or pledge campaign, signed by pregnant women,
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their midwives and community leaders, now committed whole ‘Desa SIAGA’ to providing all four BP/CR schemes (MNH 2004). The media campaign was complemented with clinical training sessions, radio vignettes and discussion groups, and a focused implementation in West Java and Banten Provinces. With each phase of the campaign linked by consistent colours and logos, and the popular singer Iis Dahlia a featured spokesperson, ‘SIAGA’ was now well established as ‘a safe motherhood brand name’ (MNH 2004). The 2004 evaluation of the ‘SIAGA’ campaign reported significantly improved knowledge of all risk factors in media-exposed communities compared with control communities, increased antenatal clinic attendance and significantly increased use of skilled birth attendants—70% of women exposed to the campaign compared with 44% in those unexposed (Sood et al. 2004b, pp. 28–45)—though a significant association with skilled attendance at delivery could not be demonstrated (Sood et al. 2004a).
Indonesian Women Health and Family Welfare Project (2000–06); SISKES Project (2006–09): ‘Desa SIAGA’ expands While the ‘SIAGA’ programmes evolved in populous provinces of Java, Sulawesi and Sumatra, the Australian Agency for International Development (AusAID) funded IWHFW Project was seeking to improve the health of women and children in Nusa Tenggara Timur (NTT) and NTB provinces (Hull et al. 1998). Evaluation of their initial programme redirected this towards stronger articulation with the MoH’s Making Pregnancy Safer strategies, adding a community development perspective to ‘Desa SIAGA’ as developed by the MNH Project (AusAID 2004; KangGURU 2005). The ‘Desa SIAGA’ concept of the MNH Project was adapted to the local context, and a fifth element, the ‘Family Planning Information Post’ added to disseminate Family Planning information, particularly to new mothers soon after giving birth (see Figure 2) (KangGURU 2005).
Figure 2 Five elements of Desa SIAGA.
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The community participation components were shifted from the control of the Provincial and District Health offices, and a nongovernment organization with experience in community empowerment—Badan Pemberdayaan Masyarakat Desa—was contracted to ensure successful community engagement. The Family Planning Information Post was organized through the provincial/ district office of the Family Planning Coordination Board, the Badan Koordinasi Keluarga Berencana (SISKES 2009a). By 2006 some 20 villages had been established as ‘Desa SIAGA’ under this project, with independent evaluation noting the sustained establishment of the five ‘Desa SIAGA’ elements in each of the six districts studied, together with anecdotal evidence of changes in men’s behaviour towards their pregnant wives, supporting them through pregnancy and delivery (Eyben 2007). Success as an AusAID funded pilot programme lead to the scale up of a further 50 villages in NTT and 90 in NTB, through the German Technical Cooperation (GIZ)1 SISKES project between 2006 and 2009. This was cofunded by the United Kingdom’s Department for International Development (DfID). Independent evaluation in 2009 of the 90 NTB facilities found more than 80% of pregnant women were aware of financial and transport support available through their registration for ‘Desa SIAGA’, with just under 70% aware of the blood donor system. Satisfaction with MNH services had consistently increased over a 2-year period, and attendance by husbands at antenatal visits had risen from 17 to 49%, and during childbirth, from 62 to 78% (Fachry and Sofiarini 2009). At a central level, the MoH was increasingly aware of the success of ‘Desa SIAGA’ as a mechanism for mobilizing local communities to provide registration, finance, transportation, blood transfusion and family planning systems, and in 2006, decided to roll the programme out nationally (Eyben 2007, p. 4). Confronted by the recent threats of avian influenza and natural disaster—the 2004 Aceh tsunami, the 2006 Merapi volcanic eruption and the recurrent risk of earthquake, flooding—the MoH now redefined ‘Desa SIAGA’ as an expanded programme, with responsibility now relocated from MNH to the MoH Health Promotion Centre. The brief of the alert village was extended to include disaster preparedness, disease surveillance and health promotion, despite early concerns around the capacity of the community to manage these tasks (Thabrany 2006; Eyben 2007, p. 4; Suryahadi et al. 2010, pp. 18–19; Mei and Lavigne 2012). GIZ, in its SISKES project, continued to focus on the Safe Motherhood components of ‘Desa SIAGA’, and having identified the lack of process guidelines for community empowerment in developing ‘Desa SIAGA’, documented its experience in this area (SISKES 2009a,b). Experienced Indonesian development trainers recognized the local equivalent of the Javanese ‘gotong royong’ in local expressions for community self-help— ‘banjar kawin’ and ‘banjar kematian’ for Sasak society, and ‘mboloweki’ for ethnic groups in Sumbawa society—and used these to locate ‘Desa SIAGA’ within local cultures (SISKES 2009b). The project worked with Provincial and District Health Offices (Sofiarini and Goeman 2009a), using local NGOs to develop a participatory learning approach to develop ‘Desa SIAGA’ (Fachry and Sofiarini 2009). Post hoc evaluation of the project at five, and subsequently 16 months after its conclusion, has shown ‘Desa SIAGA’ to be the most sustainable of all
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interventions introduced during the SISKES project (Goeman et al. 2011), attributed largely to community recognition of the value of the processes of community empowerment. From 2000 to 2009, a total of 160 villages had participated in the ‘Desa SIAGA’ projects in NTT and NTB. Yet, in 2009, 888 of these Provinces’ 911 villages would be declared ‘Desa SIAGA’ through the national programme managed by the Health Promotion Centre, applying very different criteria to the title.
Directorate of Maternal and Child Health (2005): ‘SIAP ANTAR JAGA’—‘SIAGA’ rolled out nationally But the persistent SISKES programme emphasis on safe motherhood was consistent with other national policy directions promoted by the MoH Directorate of MCH, which now fully adopted ‘SIAGA’, making it integral to its MNH strategies, and repackaging the acronym in an expanded form: ‘SIAP ANTAR JAGA’. In 2006, it was incorporated into the Making Pregnancy Safe strategy, and a ‘SIAP ANTAR JAGA’ implementation package was distributed nationally, with the endorsement of the Director General of Community Health. Villages were considered ‘ready to bring, ready to take care’— ‘DSAJ’—if their community offered the four key activities: notification of pregnant women, savings for pregnant women and the creation of a social fund, provision of transportation and availability of blood donors (MCH 2006).
Health Promotion Centre National Programme (2006): ‘DESI’—‘Desa SIAGA’ redefined nationally The success of the MNH ‘SIAGA’ campaigns, and the subsequent ‘SIAP ANTAR JAGA’ programme had not gone unnoticed. The 2004 Aceh tsunami, with its 230 000 deaths, and the Indonesian archipelago’s susceptibility to natural disaster, made community self-help and local preparedness increasingly imperative. From 2000—the year after the launch of ‘Suami SIAGA’—the Provincial Health Office of Central Java had been working with communities to establish Community Health Centres, ‘Pos Kesehatan Desa’—abbreviated as ‘POSKESDES’— offering basic primary health care, including growth monitoring of children and antenatal care for pregnant women and also community-based disease surveillance, outbreak notification and control and disaster preparedness. For the Head of this office (subsequently Director General of Community Health), the sustained potential of the ‘SIAGA’ brand at national level offered a platform for much more than safe motherhood strategies. In 2006, the ‘SIAGA’ brand underwent a significant reinterpretation. The National ‘DESA SIAGA’ programme, established by MoH decree (MoH 2006), now explicitly linked the criteria for ‘DESA SIAGA DeSi’ to the establishment of a ‘POSKESDES’, with a ‘bidan di desa’, and two trained ‘Kaders’—health volunteers—available to assist her. With this infrastructure, the networks created could address a wide spectrum of community issues: disaster, disease outbreaks, poor nutrition, poor healthy lifestyle and degradation of the environment. ‘DESA SIAGA’ was now truncated to ‘DeSi’ to avoid confusion with the continuing MCH coordinated ‘SIAP ANTAR JAGA’ programme, and the SISKES programmes in NTT and NTB. The decree guidelines for the ‘DESA SIAGA DeSi’ described them as communities that are aware of, and have the intention and
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Table 2 ‘Desa Siaga Aktif’ assessment criteria Criteria
Categories of ‘Desa Siaga Aktif’ Initial
Middle
Advanced
Self-relying
1. Village Forum
Exists but not conducted
Conducted but less than quarterly
Implemented quarterly
Implemented monthly
2. Community health workers (Kader)
At least 2 persons
3–5 persons
6–8 persons
9 persons
3. Ease of access to Primary Health Services
Yes
Yes
Yes
Yes
4. Posyandu and other community-based health programmes
Posyandu exists, but other communitybased health programmes not active
Posyandu exists and two other communitybased health programmes active
Posyandu exists and three other community-based health programmes active
Posyandu exists and four other communitybased health programmes active
5. Financial support for health activities at the village level:
Fund comes from village administration but not from other sources
Fund comes from village administration and one other additional source
Fund comes from village administration and two other additional sources
Fund comes from village administration and two other additional sources
6. Participation of community and community organizations
Community actively participate but mass organization not yet participating
Community and one mass organization actively participates
Community and two mass organizations actively participate
Community and more than two mass organizations actively participate
7. Village regulation or Regent/Mayor Regulation
Does not exist
Exists but not implemented
Exists and implemented
Exists and implemented
8. Support for healthy lifestyle at household level
Support for healthy lifestyle provided to
Health Policy and Planning 2014;29:409–420 doi:10.1093/heapol/czt027
‘Desa SIAGA’, the ‘Alert Village’: the evolution of an iconic brand in Indonesian public health strategies Peter S Hill,1* Lieve Goeman,2 Rahmi Sofiarini3,4 and Maddi M Djara4 1
Australian Centre for International and Tropical Health, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia, Sector and Thematic Expertise, Belgian Development Agency, Hoogstraat 147, 1000 Brussels, Belgium, 3USAID—IMACS Project Chemonics International, Jl. Bung Hatta No. 19, Mataram 83121, Indonesia and 4Consolidation Programme Health/Policy Analysis and Formulation in the Health Sector (PAF), Deutsche Gesellschaft fu ¨ r International Zusammenarbeit (GIZ) GmbH, Mataram 83121, Indonesia 2
*Corresponding author. Australian Centre for International and Tropical Health, The University of Queensland, Herston Road, Herston, 4006 Queensland, Australia. E-mail: [email protected]
Accepted
8 April 2013 In 1999, the Ministry of Women’s Empowerment in Indonesia worked with advertisers in Jakarta and international technical advisors to develop the concept of ‘Suami SIAGA’, the ‘Alert Husband’, confronting Indonesian males with their responsibilities to be aware of their wives’ needs and ensure early access if needed to trained obstetrics care. The model was rapidly expanded to apply to the ‘Desa SIAGA’, the ‘Alert Village’, with communities assuming the responsibility for awareness of the risks of pregnancy and childbirth, and supporting registered pregnant mothers with funding and transportation for emergency obstetric assistance, and identified blood donors. Based on the participant observation, interviews and documentary analysis, this article uses a systems perspective to trace the evolution of that iconic ‘brand’ as new national and international actors further developed the concept and its application in provincial and national programmes. In 2010, it underwent a further transformation to become ‘Desa Siaga Aktif’, a national programme with responsibilities expanded to include the provision of basic health services at village level, and the surveillance of communicable disease, monitoring of lifestyle activities and disaster preparedness, in addition to the management of obstetric emergencies. By tracking the use of this single ‘brand’, the study provides insights into the complex adaptive system of policy and programme development with its rich interactions between multiple international, national, provincial and sectoral stakeholders, the unpredictable responses to feedback from these actors and their activities and the resultant emergence of new policy elements, new programmes and new levels of operation within the system.
Keywords
Indonesia, Desa SIAGA, branding, entertainment-education, safe motherhood, community empowerment, policy analysis
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KEY MESSAGES 0002
Branding in public health interventions has the potential to provide high level of message recognition.
0002
Systems thinking provides a policy perspective across the system as a whole rather than within narrow disciplinary or programmatic frames.
0002
‘Desa SIAGA’, the ‘Alert Village’ has developed community awareness and strategies for responding to complications of pregnancy in Indonesia.
0002
The redeployment of the brand ‘Desa SIAGA’ in different disciplinary and programmatic areas has changed its connotations and risks confusion, eroding brand value.
In October 2010, the Ministry of Health (MoH) of the Republic of Indonesia issued a new decree providing general guidelines on the development of ‘Desa Siaga Aktif’, a programme designed to promote ‘Active Alert Villages’. These were defined as villages capable of providing basic health care services and safe water and basic sanitation services, undertaking community-based disease surveillance, encouraging healthy lifestyles and using community empowerment to respond to health emergencies and natural disasters (MoH 2010). The MoH has set itself a target of 80% of its current 75 410 villages achieving ‘Desa Siaga Aktif’ status by 2015 (MoH 2010). The decree reflects more than a decade of evolution of the concept of ‘siaga’—‘alert’, emerging originally from an information, education and communication campaign targeting husbands’ roles in safe motherhood (Shefner-Rogers and Sood 2004), and redefined and repackaged progressively until this most recent expression as a national mandate for village community mobilization. This article explores the evolution of this highly charged creative concept ‘siaga’ in health programmes in Indonesia, beginning with its original use and tracking its subsequent iterations. It examines the changes in organizational ‘ownership’ of the concept, and its application across a number of programme frameworks: initially as multimedia ‘entertainment-education’ health promotion, focusing on the husband’s (then community’s) responsibility for safe delivery; subsequently through ‘demand’ side community mobilization for safe motherhood, with an emphasis on community empowerment and currently in its application as a ‘top-down’ decentralized strategy shifting responsibility for ensuring basic health care, disease and lifestyle surveillance and disaster preparedness to local communities. Table 1 summarizes the key developments. In this context of changing programmes and disciplines in a dynamic policy environment, the concept ‘siaga’ has evolved as a ‘brand’. The process of branding reduces and synthesizes a complex of processes into a single, richly charged signifier that communicates the sense of the whole (Ogden et al. 2003; Walt et al. 2004; Basu and Wong 2009). This analysis explores the ways in which ‘siaga’ is employed as a brand across these diverse transitions, and questions the extent to which it can retain its function and rich connotations through these processes of change. The analysis uses systems thinking as its theoretical approach, and locates this within current explorations in policy analysis that frame health systems as complex adaptive systems (Sterman 2006; Walt et al. 2008; Hill 2011). Systems thinking is . . . an approach to problem solving that appreciates the very nature of complex systems as dynamic, constantly
changing, governed by history and by feedback, where the role and influence of stakeholders and context is critical, and where new policies and actions (of different stakeholders) often generate counterintuitive and unpredictable effects. (Adam and de Savigny 2012) By tracking the use of this single brand across changing agencies, government ministries, departments and programmes, the study provides insights into the complex adaptive system of policy and programme development (Cilliers 1998; Gatrell 2005; Adam and de Savigny 2012) with its rich interactions between multiple international, national, provincial and sectoral stakeholders, the unpredictable responses to feedback from these actors and their activities and the resultant emergence of new policy elements, new programmes and new levels of operation within the system.
‘Siaga’: alert The specific, technical use of ‘siaga’ in health promotion appears first in the ‘Suami SIAGA’ campaign in 1999, a ‘multimedia entertainment-education intervention’ in Indonesia. This programme targeted husbands with messages about their responsibilities around birth, and subsequently trained midwives and community leaders in strategies for prevention of maternal mortality (Shefner-Rogers and Sood 2004). The Ministry for the Role of Women—now the Ministry of Women’s Empowerment—worked with Indonesian advertisers and technical advisors from the Johns Hopkins University Centre for Communication Programs to develop the campaign’s creative concept ‘Suami SIAGA’, ‘Alert Husband’. Substantial qualitative formative research was used to develop and test the concept, which was then integrated into a wave of multimedia strategies: print-based communication, and national television and radio broadcasts. ‘Suami SIAGA’ messages were integrated into radio drama series and a three episode entertainment-education television mini-series broadcast between February 1999 and August 2000 (Shefner-Rogers and Sood 2004). Impact evaluation of the campaign, conducted 10 months into the project demonstrated high levels of knowledge of the key messages, including the need to accompany their wives to antenatal check-ups (89%) and delivery (88%), to recognize danger signs in pregnancy (83%) and to ensure adequate post-natal care (85%). Some 44% of husbands interviewed characterized this as new knowledge; 56% had already communicated their commitment to take action as
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Table 1 Chronological development of Desa SIAGA concepts Programme/Project
Agencies
Year
SIAGA concept
Coverage/content
MNH Project Location: National Media Campaign with focus on East Java, South Sulawesi and South Sumatra
Ministry of Role of Women, Family Planning Coordination Board, JHU/CCP, Program for Appropriate Technology in Health, USAID
1999–2004
MNH Project
Safe motherhood
February 1999– August 2000
Suami SIAGA
‘Alert husband’ aware of possible complications, arranges transport and funds prior to childbirth, ensures antenatal care for wife and delivery in a health facility
November 2001
Warga SIAGA
Ready citizens to assist with identifying risk, providing transport, funds and blood donors
2002–04
Bidan SIAGA
Ready midwife, media promotion, with training activities and radio vignettes
2002–04
Desa SIAGA
Alert village, collaborating in providing: (1) (2) (3) (4)
IFHFW Project Location: NTT and NTB provinces
AusAID and Provincial Health Office, NTT and NTB
2000–06
Identification of pregnant women Coordination of transport Blood donors Funds for treatment
Dai SIAGA
Alert religious leaders should raise community awareness and support values of Desa SIAGA
Wartewan SIAGA
Alert journalists should raise awareness in communities of maternal mortality and community action to prevent deaths
Pesantren SIAGA
Alert Islamic institutions/boarding schools should teach awareness and support for pregnant women
Desa SIAGA
AusAID takes over concept from USAID: same term, same target group: the community Same content: MNH but adding one component (1) (2) (3) (4) (5)
Identification of pregnant women Transport Blood Fund Family Planning info Post
Other implementation partners. Making Pregnancy Safer Location: National
MoH
2000–06
Directorate of Maternal and Child Health; Director-General of Community Health
2005
GTZ, cofunded by DfID, with Provincial Health Office, NTT and NTB.
SIAP ANTAR JAGA
Nationwide Demand-side approach four components: (1) (2) (3) (4)
2006
SISKES, Desa SIAGA Project Location: NTT and NTB
Extension of coverage of antenatal care, delivery and post-partum care; skilled birth attendance; family planning; capacity building and equipping of health facilities; improved referral systems.
2006–09
Identification of pregnant women Transport Blood Fund
Kit developed and SIAP ANTAR JAGA officially part of the national Making Pregnancy Safer strategy
Foreword (¼endorsement) by DG Community Health
P4K ‘Birth planning and complication readinesswith sticker’
Change to supply side strategy to avoid confusion over two DESA SIAGA programmes
Desa SIAGA
Extension of AusAID funded DESA SIAGA project with five components including family planning. Emphasis on community empowerment with development of resources for training of village participants in conjunction with PHO
In 2008: split of MCH directorate into separate Maternal Health and Child Health directorates.
(continued)
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Table 1 Continued Programme/Project
Agencies
Year
SIAGA concept
Coverage/content
DESA SIAGA Comprehensive Location: National
MoH, Health Promotion Unit
2006 Decree MoH
DESI or DESA SIAGA Comprehensive
Based on success of Central Java (Polindes-based community activities) and SIAP ANTAR JAGA Expansion of Desa Siaga: now for all villagers and all health problems: outbreaks, growth monitoring, disaster, drug shops, health emergencies. Result 2009: 56% of all villages is considered a DESI. Indicator is having a POSKESDES. Target: All villages DESA SEHAT in 2010
Minimal Service Standards Location: National
MoH
2008
Desa Siaga Aktif
Target 80% of all villages Desa Siaga Aktif by 2014. Criteria for Desa Siaga Aktif are not defined
Desa Siaga Aktif Location: National
MoH, Health Promotion Unit
2010 Decree MoH
Desa Siaga Aktif
Formalization of Desa Siaga Aktif to revitalize DESA SIAGA DESI. Extensive mechanism with eight targets, four levels of activity to measure ‘activeness’ of the village. SIAP ANTAR JAGA and DS DESI discontinued
exposure to the campaign on knowledge of community based life saving schemes’ (Sood et al. 2004a). The word ‘siaga’ means alert in Bahasa Indonesia—Indonesia’s ‘lingua franca’—but, in a semantic shift common to Bahasa, ‘SIAGA’ (capitalized in its technical use) has been unpacked as an acronym comprising elements of three separate words: ‘SIap, Antar, jaGA’. Put literally, ‘siap’ means ‘ready’, ‘antar’ ‘to take, to transport’ and ‘jaga’ ‘to guard’. But for the purposes of the ‘Suami SIAGA’ campaign, ‘siap’ was redefined as connoting husbands’ alertness to their wives’ needs in any unexpected emergency; ‘antar’, preparedness in terms of available transportation and preidentified blood donors and ‘jaga’, being present and vigilant against the risks of pregnancy, and during and after delivery (Figure 1) (Shefner-Rogers and Sood 2004). This semantic shift is common in both the formal rhetoric of Bahasa Indonesia, and in vernacular speech. Indonesia’s first president, Sukarno used similar wordplay in his political oratory (Keane 1997). Acronyms in formal, bureaucratic contexts are ubiquitous. Acronyms and neologisms also occur in more common usage, and may incorporate elements from local languages from within Indonesia’s multilingual archipelago, or international languages: English or less commonly, Dutch. Intellectualized language play is socially valued (Keane 1997), as is more mischievous language play: the acronym ‘Puskesmas’, or ‘Public Health Centre’ has been constructed from ‘PUSat KESehatan MASyarakat’, but critics of the quality of service its offers may tauntingly reconstruct its derivation as ‘PUSing KESeleo MASuk angin’: ‘nauseous, sprained, feverish’ (Chambert-Loir and Collins 1984).
Methods Figure 1 Siap Antar Jaga poster.
‘Suami SIAGA’ (Shefner-Rogers and Sood 2004). In 2004, evaluation of the impact of the ‘Desa SIAGA’ programme on married women showed increased awareness of the danger signs for pregnancy, with a ‘strong dose–response effect of
The research is a retrospective case study (Yin 2003), examining the evolving use of the concept SIAGA in Indonesia. This article uses qualitative methods as advocated by Reniscow and Page (2008) and Adam and de Savigny (2012) to explore the complex non-linear variables that have influenced policy and programmatic change in this complex policy environment.
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It brings together documentary and policy analysis with key informant interviews, and triangulates the findings from these sources with direct participation in the Indonesian Women’s Health and Family Welfare (IWHFW) Project (2000–06) and participation in the SISKES (Strengthening District Health Systems) project and its evaluation (Sofiarini 2007; Fachry and Sofiarini 2009; Birdsall and Hill 2011; Goeman et al. 2011). Key informant interviews included the Head of the Health Promotion Centre, and the Head of the Sub-Directorate of Delivery and Post-partum in the Directorate of Maternal Health and their senior staff, in the MoH Jakarta, and central and provincial health officials previously involved in ‘Desa SIAGA’ programmes. Site visits in Nusa Tenggara Barat (NTB) allowed observation of ‘Desa Siap Antar Jaga’ (DSAJ) activities in Bima, Banyu Malek and Penanae, and interviews with Provincial and District Health Officers, and with Village ‘Desa SIAGA’ Committees and trainers, facilitators and coordinators. The development of the analysis has been undertaken iteratively. The chronology of the development of ‘SIAGA’ was mapped from previous participation and key informant interviews, and a comprehensive literature search for the search term ‘SIAGA’ using PubMED, Medline Ovid and Google, Google scholar provided additional data. Emergent key themes were used to organize the findings within a framework of critical discourse analysis (Rogers et al. 2005; Carey and Gelaude 2008; Corbin and Strauss 2008, pp. 162–3): brand identification; changes in brand communication and management; national, local and international actors in health; relationships between the state, community and individuals and understandings of risk and response.
The initial context: safe motherhood in Indonesia (1988–99) In 1987, the Safe Motherhood Conference in Nairobi launched the international Safe Motherhood Initiative, calling for a reduction of maternal mortality by one half by 2000 (World Bank 2011). The following year, Indonesia launched its own Safe Motherhood Initiative (Geefhuysen 1999), aiming to reduce the country’s maternal mortality ratio (MMR) from 450 to 340 per 100 000 live births by 1993. But the release of an estimate of MMR of 390 for the period 1990–94 from the Indonesian Demographic and Health Survey 1994 (BPS and ORC Macro 1994) was well above the anticipated level, and caused significant political concern, particularly given the concerted investment in the training and distribution of village midwives (‘bidan di desa’) (Shiffman 2003). The 1995 Beijing Conference on Women provided an impetus for further action, and the following year, the Ministry for the Role of Women, galvanized by Assistant Minister Abdullah Cholil, consolidated their commitment to renewing safe motherhood activities under the banner of ‘Gerakan Sayang Ibu’—the Movement to Cherish Mothers (Geefhuysen 1999; Shiffman 2003). In 1998, the Ministry for the Role of Women partnered with the UNFPA and the Johns Hopkins University Centre for Communication Programs to trial the ‘Suami SIAGA’ project (JHUCCP 2004).
Maternal and Newborn Health Project (1999–2004): the SIAGA campaign The multi-partnered Maternal and Newborn Health (MNH) Project built on a decade of Indonesian government attention to
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the issues of safe motherhood. The media campaigns had national coverage, but focused on three high priority provinces: East Java, South Sulawesi and South Sumatra (Shefner-Rogers and Sood 2004). Formative research for the campaign had confirmed the common perception that pregnancy and delivery were in the woman’s domain, ‘a woman’s secret’ (Shefner-Rogers and Sood 2004). But recognizing that at critical points during pregnancy and childbirth decision making may pass from the pregnant woman to her husband, ‘important gatekeepers of maternal healthcare’ (Thaddeus and Maine 1994; Sciortino 1998), the campaign focused primarily on males of reproductive age, promoting behaviours for husbands that would reduce delays in seeking obstetric care, accessing appropriate services and receiving necessary interventions—particularly emergency obstetric care. In 2000, the MoH now released its Making Pregnancy Safer strategy, based on the WHO initiative (WHO 2000; Mize 2003). The strategy targeted ‘supply side’ issues through improving coverage and quality of health services, personnel and referral networks; and ‘demand side’ issues with a health promotion framework that sought to empower ‘women, men, families and communities’ as partners for improving MNH (Portela and Santarelli 2003). Based on the success of the initial ‘Suami SIAGA’ evaluations, the ‘SIAGA’ campaign was extended to embrace the whole ‘Desa SIAGA’ as an alert village, and the role of the alert midwife, the ‘Bidan SIAGA’, became more central. There had been a conscious programme shift from ‘entertainment-education’ to community mobilization: whole communities were now encouraged to formalize systems that would provide notification of pregnant women, coordinate transport, collect funding and develop blood donation registers that would ensure safe motherhood (Titaley et al. 2010). Coordination was managed through the Provincial and District Health Offices, with 55 ‘Desa SIAGA’ created in areas supported by the MNH Project (JHUCCP 2004). The MNH Project now integrated ‘Warga SIAGA’ (alert citizens) into the structure of the ‘Desa SIAGA’, reinforcing the ‘gotong royong’ community self-help focus of the campaign (MNH 2004). Endorsement from local Islamic religious leaders was sought, and readings from the Koran were included in the media campaigns (JHUCCP 2004). ‘Dai SIAGA’, alert religious leaders, were now encouraged to promote the values of the ‘Desa SIAGA’, offering solace in the case of maternal or neonatal death, but promoting their prevention. Their religious boarding schools were to become ‘Pesantren SIAGA’, supporting community initiatives to protect pregnant mothers. ‘Wartawan SIAGA’—alert journalists—were asked to report deaths and also to promote the ‘Desa SIAGA’ strategies that could prevent them. Media campaigns positioned the ‘Bidan SIAGA’—the alert midwife—as the preferred obstetric provider, inferring their technical superiority over traditional birth attendants, with calendars featuring an attractive young woman and the slogan: ‘Ayo ke bidan siaga’ (‘Come on, let’s go to the alert midwife’) (Devries 2004). The ‘Bidan SIAGA’ training was developed using birth preparedness/complication readiness (BP/CR) frameworks ‘recognising danger signs and preparing for childbirth by saving funds, arranging for transportation to a health facility if necessary, and identifying a skilled provider and birthing place’ (JHUCCP 2004), and sat very comfortably with the MoH’s Making Pregnancy Safer strategy. The ‘Kartu Amanat Persalinan’ or pledge campaign, signed by pregnant women,
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their midwives and community leaders, now committed whole ‘Desa SIAGA’ to providing all four BP/CR schemes (MNH 2004). The media campaign was complemented with clinical training sessions, radio vignettes and discussion groups, and a focused implementation in West Java and Banten Provinces. With each phase of the campaign linked by consistent colours and logos, and the popular singer Iis Dahlia a featured spokesperson, ‘SIAGA’ was now well established as ‘a safe motherhood brand name’ (MNH 2004). The 2004 evaluation of the ‘SIAGA’ campaign reported significantly improved knowledge of all risk factors in media-exposed communities compared with control communities, increased antenatal clinic attendance and significantly increased use of skilled birth attendants—70% of women exposed to the campaign compared with 44% in those unexposed (Sood et al. 2004b, pp. 28–45)—though a significant association with skilled attendance at delivery could not be demonstrated (Sood et al. 2004a).
Indonesian Women Health and Family Welfare Project (2000–06); SISKES Project (2006–09): ‘Desa SIAGA’ expands While the ‘SIAGA’ programmes evolved in populous provinces of Java, Sulawesi and Sumatra, the Australian Agency for International Development (AusAID) funded IWHFW Project was seeking to improve the health of women and children in Nusa Tenggara Timur (NTT) and NTB provinces (Hull et al. 1998). Evaluation of their initial programme redirected this towards stronger articulation with the MoH’s Making Pregnancy Safer strategies, adding a community development perspective to ‘Desa SIAGA’ as developed by the MNH Project (AusAID 2004; KangGURU 2005). The ‘Desa SIAGA’ concept of the MNH Project was adapted to the local context, and a fifth element, the ‘Family Planning Information Post’ added to disseminate Family Planning information, particularly to new mothers soon after giving birth (see Figure 2) (KangGURU 2005).
Figure 2 Five elements of Desa SIAGA.
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The community participation components were shifted from the control of the Provincial and District Health offices, and a nongovernment organization with experience in community empowerment—Badan Pemberdayaan Masyarakat Desa—was contracted to ensure successful community engagement. The Family Planning Information Post was organized through the provincial/ district office of the Family Planning Coordination Board, the Badan Koordinasi Keluarga Berencana (SISKES 2009a). By 2006 some 20 villages had been established as ‘Desa SIAGA’ under this project, with independent evaluation noting the sustained establishment of the five ‘Desa SIAGA’ elements in each of the six districts studied, together with anecdotal evidence of changes in men’s behaviour towards their pregnant wives, supporting them through pregnancy and delivery (Eyben 2007). Success as an AusAID funded pilot programme lead to the scale up of a further 50 villages in NTT and 90 in NTB, through the German Technical Cooperation (GIZ)1 SISKES project between 2006 and 2009. This was cofunded by the United Kingdom’s Department for International Development (DfID). Independent evaluation in 2009 of the 90 NTB facilities found more than 80% of pregnant women were aware of financial and transport support available through their registration for ‘Desa SIAGA’, with just under 70% aware of the blood donor system. Satisfaction with MNH services had consistently increased over a 2-year period, and attendance by husbands at antenatal visits had risen from 17 to 49%, and during childbirth, from 62 to 78% (Fachry and Sofiarini 2009). At a central level, the MoH was increasingly aware of the success of ‘Desa SIAGA’ as a mechanism for mobilizing local communities to provide registration, finance, transportation, blood transfusion and family planning systems, and in 2006, decided to roll the programme out nationally (Eyben 2007, p. 4). Confronted by the recent threats of avian influenza and natural disaster—the 2004 Aceh tsunami, the 2006 Merapi volcanic eruption and the recurrent risk of earthquake, flooding—the MoH now redefined ‘Desa SIAGA’ as an expanded programme, with responsibility now relocated from MNH to the MoH Health Promotion Centre. The brief of the alert village was extended to include disaster preparedness, disease surveillance and health promotion, despite early concerns around the capacity of the community to manage these tasks (Thabrany 2006; Eyben 2007, p. 4; Suryahadi et al. 2010, pp. 18–19; Mei and Lavigne 2012). GIZ, in its SISKES project, continued to focus on the Safe Motherhood components of ‘Desa SIAGA’, and having identified the lack of process guidelines for community empowerment in developing ‘Desa SIAGA’, documented its experience in this area (SISKES 2009a,b). Experienced Indonesian development trainers recognized the local equivalent of the Javanese ‘gotong royong’ in local expressions for community self-help— ‘banjar kawin’ and ‘banjar kematian’ for Sasak society, and ‘mboloweki’ for ethnic groups in Sumbawa society—and used these to locate ‘Desa SIAGA’ within local cultures (SISKES 2009b). The project worked with Provincial and District Health Offices (Sofiarini and Goeman 2009a), using local NGOs to develop a participatory learning approach to develop ‘Desa SIAGA’ (Fachry and Sofiarini 2009). Post hoc evaluation of the project at five, and subsequently 16 months after its conclusion, has shown ‘Desa SIAGA’ to be the most sustainable of all
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interventions introduced during the SISKES project (Goeman et al. 2011), attributed largely to community recognition of the value of the processes of community empowerment. From 2000 to 2009, a total of 160 villages had participated in the ‘Desa SIAGA’ projects in NTT and NTB. Yet, in 2009, 888 of these Provinces’ 911 villages would be declared ‘Desa SIAGA’ through the national programme managed by the Health Promotion Centre, applying very different criteria to the title.
Directorate of Maternal and Child Health (2005): ‘SIAP ANTAR JAGA’—‘SIAGA’ rolled out nationally But the persistent SISKES programme emphasis on safe motherhood was consistent with other national policy directions promoted by the MoH Directorate of MCH, which now fully adopted ‘SIAGA’, making it integral to its MNH strategies, and repackaging the acronym in an expanded form: ‘SIAP ANTAR JAGA’. In 2006, it was incorporated into the Making Pregnancy Safe strategy, and a ‘SIAP ANTAR JAGA’ implementation package was distributed nationally, with the endorsement of the Director General of Community Health. Villages were considered ‘ready to bring, ready to take care’— ‘DSAJ’—if their community offered the four key activities: notification of pregnant women, savings for pregnant women and the creation of a social fund, provision of transportation and availability of blood donors (MCH 2006).
Health Promotion Centre National Programme (2006): ‘DESI’—‘Desa SIAGA’ redefined nationally The success of the MNH ‘SIAGA’ campaigns, and the subsequent ‘SIAP ANTAR JAGA’ programme had not gone unnoticed. The 2004 Aceh tsunami, with its 230 000 deaths, and the Indonesian archipelago’s susceptibility to natural disaster, made community self-help and local preparedness increasingly imperative. From 2000—the year after the launch of ‘Suami SIAGA’—the Provincial Health Office of Central Java had been working with communities to establish Community Health Centres, ‘Pos Kesehatan Desa’—abbreviated as ‘POSKESDES’— offering basic primary health care, including growth monitoring of children and antenatal care for pregnant women and also community-based disease surveillance, outbreak notification and control and disaster preparedness. For the Head of this office (subsequently Director General of Community Health), the sustained potential of the ‘SIAGA’ brand at national level offered a platform for much more than safe motherhood strategies. In 2006, the ‘SIAGA’ brand underwent a significant reinterpretation. The National ‘DESA SIAGA’ programme, established by MoH decree (MoH 2006), now explicitly linked the criteria for ‘DESA SIAGA DeSi’ to the establishment of a ‘POSKESDES’, with a ‘bidan di desa’, and two trained ‘Kaders’—health volunteers—available to assist her. With this infrastructure, the networks created could address a wide spectrum of community issues: disaster, disease outbreaks, poor nutrition, poor healthy lifestyle and degradation of the environment. ‘DESA SIAGA’ was now truncated to ‘DeSi’ to avoid confusion with the continuing MCH coordinated ‘SIAP ANTAR JAGA’ programme, and the SISKES programmes in NTT and NTB. The decree guidelines for the ‘DESA SIAGA DeSi’ described them as communities that are aware of, and have the intention and
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Table 2 ‘Desa Siaga Aktif’ assessment criteria Criteria
Categories of ‘Desa Siaga Aktif’ Initial
Middle
Advanced
Self-relying
1. Village Forum
Exists but not conducted
Conducted but less than quarterly
Implemented quarterly
Implemented monthly
2. Community health workers (Kader)
At least 2 persons
3–5 persons
6–8 persons
9 persons
3. Ease of access to Primary Health Services
Yes
Yes
Yes
Yes
4. Posyandu and other community-based health programmes
Posyandu exists, but other communitybased health programmes not active
Posyandu exists and two other communitybased health programmes active
Posyandu exists and three other community-based health programmes active
Posyandu exists and four other communitybased health programmes active
5. Financial support for health activities at the village level:
Fund comes from village administration but not from other sources
Fund comes from village administration and one other additional source
Fund comes from village administration and two other additional sources
Fund comes from village administration and two other additional sources
6. Participation of community and community organizations
Community actively participate but mass organization not yet participating
Community and one mass organization actively participates
Community and two mass organizations actively participate
Community and more than two mass organizations actively participate
7. Village regulation or Regent/Mayor Regulation
Does not exist
Exists but not implemented
Exists and implemented
Exists and implemented
8. Support for healthy lifestyle at household level
Support for healthy lifestyle provided to