45589 RESEARCH REPORT Qualitative Baseline Study for PNPM Generasi and PKH: The Availability and Use of the Maternal and Child Health Services and Basic Education Services in the Provinces of West Java and East Nusa Tenggara Sri Kusumastuti Rahayu Nina Toyamah Stella Aleida Hutagalung Meuthia Rosfadhila Muhammad Syukri Translators/Editors: Kate Weatherley Budhi Adrianto Liza Hadiz The SMERU Research Institute Jakarta, July 2008 The findings, views, and interpretations published in this report are those of the authors and should not be attributed to The SMERU Research Institute or any of the agencies providing financial support to SMERU. For further information, please contact SMERU, phone: 62-21-31936336; fax: 62-21-31930850; e-mail: smeru@smeru.or.id; website: www.smeru.or.id Qualitative Baseline Study for PNPM Generasi and PKH: The Availability and Use of the Maternal and Child Health Services and Basic Education Servicesinthe Provinces ofWest Java and East Nusa Tenggara/SriKusumastutiRahayu et al. -- Jakarta: The SMERU Research Institute, 2008. xxi, 102 p. ; 30 cm. -- (Research Report SMERU, July 2008) ISBN 978-979-3872-55-1 1. Conditional Cash Transfer I. SMERU II. Rahayu, Sri Kusumastuti 361.05 / DDC 21 RESEARCH TEAM Supervisor: Sudarno Sumarto Research Coordinator: Sri Kusumastuti Rahayu Advisor: Asep Suryahadi Core Team and Field Coordinators: Sri Kusumastuti Rahayu Nina Toyamah Stella Aleida Hutagalung Meuthia Rosfadhila Muhammad Syukri Adri Amiruddin Field Researchers: West Java: East Nusa Tenggara: Sri Kusumastuti Rahayu (Jakarta) Sri Kusumastuti Rahayu (Jakarta) Luluk Kholisoh Nurona (West Java) Laurensius Sayrani (Kupang) Supriono (West Java) Sitti Sugar Samauna (Kupang) Muhammad Syukri (Jakarta) Luluk Kholisoh Nurona (West Java) Dewi Amna (West Java) Nur Aini (Kupang) Mawardi W. Ghazali (West Java) Yans Koliham (Kupang) Stella Aleida Hutagalung (Jakarta) Harry Foenay (Kupang) Hendra W. Wardhana (West Java) Stella Aleida Hutagalung (Jakarta) Imron Hanafi (West Java) Emiliana Martuti Lawalu (Soe) Meuthia Rosfadhila (Jakarta) Agustinus Mahur (Kupang) Yudi Ardiansyah (West Java) Fredick H. Kaesmetan (Soe) Yeni Indra (West Java) Meuthia Rosfadhila (Jakarta) Nina Toyamah (Jakarta) Nikolaus Serman (Kupang) Pitriati Solihah (West Java) Aplonia Toto (Soe) Dudi Lesmana (West Java) Muhammad Syukri (Jakarta) Adri Amiruddin (Jakarta) Timoriyani Samauna (Kupang) Helmiyati (West Java) Ary CH Bale Lay (Soe) Heru Pramudhia Wardhana (West Java) Adri Amiruddin (Jakarta) Erwin Permana (West Java) Yakomina W. Nguru (Kupang) Pascalis Baylon Meja (Kefamanu) Translators/Editors: Kate Weatherley Budhi Adrianto Liza Hadiz ACKNOWLEDGEMENTS We would like to convey our gratitude and appreciation to Susan Wong and Junko Onishi from the World Bank, who initiated and facilitated this research project, for their technical guidance and valuable comments and suggestions during the course of the study. We are thankful to the Government of Indonesia, the Decentralization Support Facility (DSF), the Royal Embassy of the Netherlands, and the World Bank Indonesia, which have supported this study through their funding and technical assistance to the PNPM Generasi and PKH and their evaluations. We are grateful to all the community members, respondents, and informants in the sample areas who have taken part in the study by providing information and facts in the field. Without them, this study would not have been possible to be conducted. We appreciate the assistance given by officials at the district level, especially those from the district health offices and district education offices who provided us with data so that we were able to select the areas for the study. We also appreciate the subdistrict governments and village administrations, as well as the posyandu cadres for their hospitalities, full assistance, and valuable time spared that made discussions with the communities possible. We are also grateful to the wonderful and dedicated regional researchers during the fieldworks for their hard and excellent work without complaints, even when they had to work late at night and stay in remote villages. Finally, we are grateful for the thoughtful inputs and constructive comments from government officials of relevant ministries, donors, and other parties attending the meetings in Bappenas and DSF-The World Bank to discuss findings of the quantitative baseline survey and the qualitative baseline study of PNPM Generasi and PKH on 24 January 2008. The SMERU Research Institute iii ABSTRACT Qualitative Baseline Study for PNPM Generasi and PKH: The Availability and Use of the Maternal and Child Health Services and Basic Education Services in the Provinces of West Java and East Nusa Tenggara This study explores the qualitative data on why some Indonesians do not use basic maternal and child health services and why some Indonesians do not send their children to primary or junior high schools, which will serve as a baseline for future PNPM Generasi (Program Nasional Pemberdayaan Masyarakat Generasi Sehat dan Cerdas) and PKH (Program Keluarga Harapan) evaluations. Based on results of FGDs, in-depth interviews, and direct observations conducted in West Java and NTT, the study finds that physical access limitations and isolation, economic access limitations, and the belief in the traditional custom are the main reasons why some community members do not use modern mother and child health services for pre- and postnatal monitoring or for delivery. Problems related to physical access and financial access are also the main reasons for attrition and why some parents do not send their children to junior high school. Keywords: Qualitative baseline data, PNPM Generasi, PKH, basic maternal and child health services, basic education services, Indonesia. The SMERU Research Institute v Reasons for using dukun beranak (traditional birth attendants): The midwife is too far away [about 4 kilometers], and there are thieves in the evening. This makes us scared to go there at night. The road there is also really bad. You feel like you want to die if you have to go there. Apart from that, the community has to cross a river that does not have a bridge, and so during the rainy season, they automatically cannot cross or reach the health facilities. (Men's FGD, Hauteas, North Biboki, TTU, NTT) If it is expected that the infant's birth will not be difficult, yes, it's good enough to use the dukun beranak. (Women's FGD, Jagapura Kidul, Gegesik, Cirebon, West Java) Reasons under-fives were not initially immunized: There are certainly children who are not immunized due to fears that they will run a high temperature after being immunized. Moreover, after watching TV, there are some who have died and become paralyzed after being immunized, so there are some community members who are scared. (Women's FGD, Jagapura Kidul, Gegesik, Cirebon, West Java) [They are] scared [that] their child will get a temperature. Then, later that night, they will be fussy and cry after the injection. (Men's FGD, Tangkil, Susukan, Cirebon, West Java) Reasons for not attending posyandu (integrated health service post): I don't want to go to the posyandu. My child's weight is not increasing ... maybe the scales are wrong. What's more[is that] if there is no supplementary food, only half of the patients attend. It's different if there is food; it's full, with a queue. (Women's FGD, Bojongloa, Buahdua, Sumedang, West Java) The parents consider their children to be healthy, so they don't need to be weighed. It [the weight] is irrelevant. (Men's FGD, Jagapura Kidul, Gegesik, Cirebon, West Java) Usually, if mothers don't take their children to the posyandu, it is because they have to walk a long way, or because of the rainy season and floods, which definitely make it harder. If they are harvesting or busy planting or clearing the grass, then they also won't come to the posyandu. (Men's FGD, Falas, Kie, TTS, NTT) A Healthy child does not always "please" the mothers: We are not satisfied because only malnourished children recieve assistance. My child won the healthy child competition, so we don't get anything. Let alone the mothers that often get assistance are jealous of those who don't get assistance. (Women's FGD, Oenenu, East Miomaffo, TTU, NTT) vi The SMERU Research Institute Benefit of schooling: In my opinion, children go to school to develop the village [in the future]. (Women's FGD, Oehela, Batu Putih, TTS, NTT) ... [so that children are] able to tell right from wrong. (Women's FGD, Fatufetto, Alak, Kupang, NTT) ... so that [my child] can speak Indonesian. (Women's FGD, Falas, Kie, TTS, NTT) ... so that [the children] can become civil servants. (Women's FGD, Sekon, Insana, TTU, NTT) Reason for not sending children to school or enroll: ... There's already a bupati, already a subdistrict head, already a village head. Who do you want to replace? (Men's FGD, Hauteas, North Biboki, TTU, NTT) Reasons for not continuing school and withdrawing from school: There is one whose father died, so they don't want to go to school. (Women's FGD, Kuanek, East Miomaffo, TTU, NTT) ... because there are a lot of influences ... influence from their outside friends. (Women's FGD, Oenay, Kie, TTU, NTT) The motorcycle taxi driver persuaded them not to go to school. (Women's FGD, Oenenu, East Miomaffo and Hauteas, North Biboki, TTU, NTT) Some also [discontinue their schooling] because they are embarrassed that they can't pay the book money. (Women's FGD, Jagapura Kidul, Gegesik, Cirebon, West Java) Reasons of being absent: Here, if there are a lot that don't come, it is always around harvest time, Sir. The problem is that they are helping their parents. It can go for 3 to 7 days. They [children] don't ask for permission because it is already the norm here. (Women's FGD, Tangkil, Susukan, Cirebon, West Java) If the uniform is torn, they don't want to go to school (Women's FGD, Sekon, Insana, TTU, NTT) When they don't do their homework, they are afraid that the teacher will be angry [and so don't want to go to school]. (Men's FGD, Taunbaen, North Biboki, TTU, NTT) [The child is] not happy with the teacher. (Men's FGD, Oenenu, East Miomaffo, TTU, NTT) The teacher is mean. (Men's FGD, Naikolan, Maulaffa, Kupang, NTT) [The child is] not happy with particular lessons. (Women's FGD, Naikolan, Maulaffa, Kupang, NTT) There are children that ask for snack money, but it is not given to them; so, they skip school. (Women's FGD, Kuanek, East Miomaffo, TTU, NTT) The SMERU Research Institute vii TABLE OF CONTENTS ACKNOWLEDGEMENTS iii ABSTRACT v TABLE OF CONTENTS viii LIST OF TABLES ix LIST OF BOXES ix LIST OF APPENDICES x ABBREVIATIONS xi EXECUTIVE SUMMARY xiii I. INTRODUCTION 1 1.1 Background 1 1.2 Study Objectives 2 1.3 Methodology 2 1.4 Sample Areas 4 1.5 Report Structure 6 II. SAMPLE REGION CHARACTERISTICS 7 2.1 Research Locations 7 2.2 Natural and Economic Resources 8 2.3 Populations 10 2.4 Community Groups and Institutions 11 2.5 Health and Education Facilities 12 2.5.1 Health Facilities 12 2.5.2 Education Facilities 13 III. AVAILABILITY AND USE OF MATERNAL AND CHILD HEALTH SERVICES 15 3.1 Supply, Conditions, and Coverage of Basic Maternal and Child Health Services 16 3.1.1 Supply of Modern MCH Service Facilities 16 3.1.2 Modern MCH Facilities and Infrastructure 18 3.1.3 Other Obstacles Faced and the Need for MCH Service Providers 19 3.1.4 Cooperation with the Community and the Reach of Specific Groups 20 3.1.5 Traditional Services 21 3.2 Demand and the Factors Influencing Demand for Maternal and Child Health Services 23 3.2.1 Community Knowledge and Awareness of the Importance of Modern MCH Services 23 3.2.2 Obstacles to Physical and Financial Accesses 29 3.2.3 Quality of Modern MCH Services 31 3.2.4 Choosing Traditional MCH Services 34 3.2.5 Actors that Influence Demand for Modern MCH Services 36 IV. SUPPLY OF AND DEMAND FOR BASIC EDUCATION SERVICES 40 4.1 Supply and Coverage of Basic Education Services 41 4.1.1 Supply and School Capacity 41 4.1.2 Obstacles that Schools Face in the Provision of Comprehensive Education Facilities 43 4.1.3 Obstacles that Teachers Face in Providing Sufficient Services 45 viii The SMERU Research Institute 4.1.4 Obstacles in Reaching Specific Groups 46 4.1.5 Service Quality 47 4.1.6 The Role of Actors and Community Participation in Supplying School Facilities 48 4.2 Demand for Basic Education Services and Factors that Influence Parents to Send Their Children to School 50 4.2.1 Community KnowledgeandAwarenessofthe Importance ofEducation 50 4.2.2 Community Choice of and Access to Existing Schools 54 4.2.3 Physical and Financial Accesses 56 4.2.4 Other Factors which Influence Primary School Graduates to Not Continue to Junior High School and Discontinue Their Education 58 4.2.5 Irregular Attendance and Influential Factors 60 4.2.6 Actors at the Village Level that Influence the Community to Send Their Children to School 61 4.2.7 Other Actors that Influence the Community to Send Their Children to School 64 V. CONCLUSION AND RECOMMENDATIONS 66 5.1 Conclusion 66 5.2 Recommendations 72 LIST OF REFERENCES 74 FURTHER READING 74 APPENDICES 78 LIST OF TABLES Page Table 1 Research Questions 3 Table 2 Research Locations 5 Table 3 Maternal Mortality, Proportion of Deliveries Assisted by a Skilled 15 Birth Attendant, Infant Mortality, and Under-five Mortality Table 4 Number of Dukun Bayi/Beranak, Trained and Untrained 22 Table 5 Posyandu Attendance Levels during Field Observation 28 Table 6 Satisfaction Levels for Modern MCH Services 32 Table 7 NER dan GER for SD and SMP, and Literacy Rates (%) 40 Table 8 Repeat Rates and Attrition Rates (%) 40 Table 9 Number of Enrolled and Graduating Students at SDK Sekon, 53 Insana, TTU LIST OF BOXES Page Box 1. Se'i 21 Box 2. Students' Education Discontinuance 52 Box 3. Conditions for Going Up to the Next Grade 54 Box 4. High Associated School Expenses 57 The SMERU Research Institute ix LIST OF APPENDICES Page Lampiran 1. List of Informants, FGDs, and Other Activities in Each Sample 79 Village/Kelurahan and Subdistrict Lampiran 2. Map of Sumedang District 80 Lampiran 3. Map of Cirebon District 81 Lampiran 4. Map of North Central Timor (TTU) District 82 Lampiran 5. Map of South Central Timor (TTS) District 83 Lampiran 6. Map of Kupang City 84 Lampiran 7. Access to Sample Villages/Kelurahan in West Java and NTT 85 Lampiran 8. Distribution of Administration Areas in Sample 86 Villages/Kelurahan in West Java and NTT Lampiran 9. Demographics of Sample Villages/Kelurahan in West Java and NTT 87 Lampiran 10. Institutions in the Sample Villages/Kelurahan in West Java and 88 NTT Lampiran 11. Availability of Modern MCH Services that are Accessible for Communities of Sample Villages/Kelurahan in West Java and 89 NTT Lampiran 12. Availability of Basic Education Facilities that can be Accessed by Sample Village/Kelurahan Communities in West Java and 90 NTT Lampiran 13. Community's Favorite MCH Service in Villages Easy to Access: 91 Prenatal, During Delivery, and Postnatal Lampiran 14. Community's Favorite MCH Service in Villages Difficult to 91 Access: Prenatal, During Delivery, and Postnatal Lampiran 15. Community's Favorite MCH Service in Cities: Prenatal, During 91 Delivery, and Postnatal Lampiran 16. Community's Favorite Place for Their Under-fives' 92 Immunization Lampiran 17. Community's Favorite Place for Weighing Their Under-fives 92 Lampiran 18. Places to Obtain Nutrition Treatment according to the Community 92 Lampiran 19. Beliefs in the Customs regarding Prenatal, During-Delivery, dan 93 Postnatal Practices in West Java and NTT Lampiran 20 Criteria of Good Schools and Teachers according to the 102 Community x The SMERU Research Institute ABBREVIATIONS Askeskin : Asuransi Kesehatan Keluarga Miskin (Health Insurance for the Poor) BOS : bantuan operasional sekolah (Operational Assistance for Schools) BPD : badan permusyawaratan desa (village people's consultative assembly) BPS : Biro Pusat Statistik (Statistics Indonesia) CCT : conditional cash transfers CWS : Christian World Service FGD : focus group discussion Gakin/JPK Gakin : Jaminan Pemeliharaan Kesehatan Keluarga Miskin (Health Care Insurance for the Poor) GER : gross enrollment rate (APK/angka partisipasi kasar) GMIT : Gereja Masehi Indonesia Timur-- Protestant Christian Churches in Eastern Indonesia IMR : infant mortality rate (AKB/angka kematian bayi) Inpres : instruksi presiden (presidential instruction) KDP : Kecamatan Development Program (PPK/Program Pengembangan Kecamatan) KTSP : kurikulum tingkat satuan pendidikan (school's self-developed curriculum) LKS : lembar kerja siswa (students' exercise sheets) MCH : maternal and child health MDGs : Millennium Development Goals MI : madrasah ibtidaiah (Islamic primary school) MMR : maternal mortality rate (AKI/angka kematian ibu) MTs : madrasah sanawiah (Islamic junior high school) NER : net enrollment rate (APM/angka partisipasi murni) NGO : nongovernment organization NTT : Nusa Tenggara Timur (East Nusa Tenggara) PKD : Pusat Kesehatan Desa (village health center) PKH : Program Keluarga Harapan (Household Conditional Cash Transfer) PKK : Program Kesejahteraan Keluarga (Family Welfare Program) PNPM Generasi : ProgramNasional PemberdayaanMasyarakat GenerasiSehatdanCerdas (Community Conditional Cash Transfer) Podes : Potensi Desa (Village Potential) polindes : pos persalinan desa (village maternity post) posyandu : pos pelayanan terpadu (integrated health service post) puskesmas : pusat kesehatan masyarakat (community health center) pusling : puskesmas keliling (mobile puskesmas) pustu : puskesmas pembantu (secondary puskesmas) RAPBS : rencana anggaran pendapatan dan belanja sekolah (school budget plan) RT : rukun tetangga RW : rukun warga SD : sekolah dasar (primary school) SDN : sekolah dasar negeri (state primary school) SDK : sekolah dasar Katolik (Catholic primary school) SKTM : surat keterangan tidak mampu (certificate of financial incapability) SMP : sekolah menengah pertama (junior high school) SMPN : sekolah menengah pertama negeri (state junior high school) TTS : Timor Tengah Selatan (South Central Timor) The SMERU Research Institute xi TTU : Timor Tengah Utara (North Central Timor) U5MR : Under-five (5) Mortality Rate (AKABA/angka kematian anak balita) Wajar Dikdas : (Program) Wajib Belajar Pendidikan Dasar (Compulsory Basic Education program) xii The SMERU Research Institute EXECUTIVE SUMMARY I. Introduction 1.1 Background In mid-2007, the Government of Indonesia launched two pilot Conditional Cash Transfer (CCT) programs: the Community Conditional Cash Transfer (PNPM Generasi Sehat dan Cerdas--PNPM Generasi) and the Household Conditional Cash Transfer (Program Keluarga Harapan--PKH). These two pilot projects will be implemented in seven provinces, starting with Gorontalo and followed by West Sumatra, DKI Jakarta (Daerah Khusus Ibukota Jakarta--Special Capital Region of Jakarta), West Java, East Java, North Sulawesi, and NTT (Nusa Tenggara Timur--East Nusa Tenggara). Both projects are designed to achieve the same objectives and goals, covering five of the eight MDGs (Millennium Development Goals): to reduce poverty and hunger, to ensure universal coverage of basic education, to promote gender equality, and to reduce maternal mortality and child mortality. Unlike previous development programs which never had baseline data, these two programs provide baseline data which are collected through a quantitative baseline survey, to be complemented by a qualitative baseline study. 1.2 Objectives Complementing the quantitative baseline survey, this qualitative study for PNPM Generasi and PKH is used to help understand how and why the two programs work. It probes deeper into questions of service provision and demand, placing particular emphasis on the provider-user interaction as well as contextual factors within the communities that influence access to, use of, and provision of health and education services. The data and qualitative study results provide a baseline that will be used to measure the impact of the program in the same areas and analyze change over time. The specific objectives of the CCT qualitative baseline study are to (1) document the baseline conditions regarding basic health and education services specified in the programs, that is, the health of pregnant mothers during pregnancy, during delivery, and post- delivery, the health of under-fives, as well as primary school and junior high school education; and (2) understand underlying causes and factors that affect use and provision of services conditioned by CCT and are likely to influence project implementation and outcomes. The main research questions are (1) why do some Indonesians not use basic maternal and child health services? and (2) why do some Indonesians not send their children to primary or junior high schools? The answers to these questions will be examined from the supply side (provision of services) and the demand side (use of services). 1.3 Methodology This study employed a qualitative approach using in-depth interviews with key informants, focus group discussions (FGDs) with community members using (or not using) the facilities including separate groups of men and women, and direct observation by researchers in posyandui and both primary and junior high schools. i pos pelayanan terpadu (integrated health service post) The SMERU Research Institute xiii The preparation stage of the study started in August 2007 and the fieldworks in 24 sample villages were conducted over one and a half months during September­October 2007. Each village spanned approximately one week. 1.4 Sample Areas The provinces of West Java and East Nusa Tenggara were covered in this qualitative baseline study. From these two provinces, four districts and one city were selected: Sumedang District and North Central Timor (TTU--Timor Tengah Utara) District-- regions that are planned to be the hosts for PNPM Generasi; as well as Cirebon District, South Central Timor (TTS--Timor Tengah Selatan) District, and Kupang City--regions that are planned to host PKH. Four treatment subdistricts, each of which is for PNPM Generasi and PKH, and three control subdistricts, each of which is for PNPM Generasi and PKH, have been selected as sample subdistricts from the aforementioned districts and city. In total, this qualitative baseline study was conducted in 24 villages, both rural and urban. II. Regional Characteristics Physical access to reach the majority of villages in NTT and isolated areas in West Java is difficult. In NTT, the majority of roads are rock-hardened and muddy when it rains. Several hamlets are separated by rivers without bridges and are thus often unable to be crossed during the rainy season. There are almost no rural transport facilities, with the exception of relatively expensive motorcycle taxis (ojek). In West Java, several villages are relatively easy to access and have sufficient transportation facilities. Some villages have rural transportation available and almost all villages have many motorcycle taxis. Nevertheless, village transportation is insufficient in several remote villages and hamlets. Farming and fishing are the main livelihoods for the majority of people. The difference is that land in NTT is infertile and rocky, while West Java is a relatively fertile area. As a result, apart from relying on cash crops such as tamarind, farmers in NTT often rent or buy land outside the village and manage it for planting various types of seasonal crops. When undertaking these activities, the whole family leaves the village for several months at a time, including women in all stages of pregnancy. Livestock are also one of the economic efforts in NTT. There are more work alternatives in West Java than in NTT, which are made possible by easier access to large cities and subdistrict capitals. Particularly in coastal areas in West Java, due to a lack of fish in areas close to the main residential areas, fishermen often have to look for fish outside the region. Like in farming families, when a fisherman leaves the village in these times, the whole family, including pregnant women and school-aged children, usually follows. The majority of villages in NTT are not properly serviced by basic facilities such as electricity and water. The lack of water and electricity as well as the poor road conditions and insuffient transportation facilities mean that village midwives and teachers are unwilling to live in the village. In the majority of the studied areas in West Java, basic facilities are sufficient, except in coastal areas in Cirebon where residents must buy water for their cooking and drinking needs. xiv The SMERU Research Institute III. Main Findings 3.1 Maternal and Child Health (MCH) Services 3.1.1 Supply There is a sufficient supply of modern MCH facilities in areas with easy access, but in areas far from reach, supply is still lacking. Village midwives, polindes,ii and posyandu are available. In several villages in West Java, communities can easily access privately practicing midwives, pustu,iii and puskesmas.iv In NTT, however, although there is a puskesmas in each subdistrict and a pustu in several subdistricts, these facilities are unpopular with communities in several areas because they are too distant. In urban areas, both in West Java and NTT, communities can access obstetricians. They can also access the closest public hospital in the event that complications arise during either pregnancy or the delivery process. In NTT, particularly in isolated areas difficult to access, not all village midwives are willing to live in the village and consequently, polindes are not operational. A lack of water has meant that a village midwife is not prepared to live in the polindes or the village. While the village midwife lives in the village, she is often not there as she is caring for her parents who live in another village. This makes it difficult for the community to access health services in the evenings or in an emergency. In NTT, broad working territories mean that village midwives cannot service the entire community, even if the village midwife resides in the village. Some hamlets are located far away from the village midwife or the polindes. Ideally, in a broad working territory, there should be more than one midwife. All villages, in fact all hamlets, have a posyandu. Almost all are active, are routinely held each month, and are well-managed by three to five cadres. Nevertheless, attendance levels for posyandu participants (pregnant women and under-fives) are still low. To date, posyandu cadres have been central to MCH services and to other community services. Unfortunately, village administrations do not fully appreciate the presence of posyandu cadres, whereas their workload is heavy starting from servicing patients in the posyandu, observing community health conditions, and providing information to completing administrative tasks. This affects community members' willingness to become a posyandu cadre and because many posyandu cadres had to leave their assignments due to economic needs--for instance, by becoming an overseas migrant worker. Village midwives face their main obstacles in servicing the community when they try to reach certain groups, which are (1) those who are unaware or not particularly aware of the importance of MCH services, such as communities that still revere the customs (adat). In NTT, this constitutes communities that still practice se'i,v while in West ii pos persalinan desa (village maternity post) iii puskesmas pembantu (secondary puskesmas) iv pusat kesehatan masyarakat (community health center) v Se'i literally means "roasting". It is a custom where a new mother has to stay in a structure equipped with a hot furnace under the bed for 40 days; hence, unreachable by village midwives. The SMERU Research Institute xv Java, this may be communities where men do not want their wife's genitals to be seen by another person; (2) farming communities that work in fields far from the main settlement; and (3) fishing communities who go to sea far from the village. Other obstacles for village midwives include the absence of transportation facilities to help them cover their large territories and isolated areas, the small number of village midwives, and irregular incomes. In NTT, village midwives are more reliant on income from the reimbursement of delivery fees from Askeskin (Asuransi Kesehatan Keluarga Miskin--Health Insurance for the Poor), which in reality are difficult to claim, while in West Java, patients are occasionally late in paying their installments for midwife services. Although their numbers are declining, dukun beranak (traditional birth attendants) are still operating. Between one and five dukun beranak are operating in each research village/kelurahan.vi In several areas in NTT, however, the number of dukun beranak are actually increasing. In NTT, while in general the community uses midwife services, in areas difficult for the village midwife to reach, dukun beranak are involved in prenatal care, mainly in checking and correcting the foetus' position, and in the delivery process. Communication and cooperation between traditional (health) service providers and (modern) MCH service providers in the majority of sample areas are good. 3.1.2 Demand In general, the majority of the community in the sample villages/kelurahan have good knowledge, understanding, and awareness of the importance of modern MCH services. Only in areas which are isolated and/or where a large number of the population is poor are there some community members who do not use modern MCH services. Some community members still only use a dukun beranak when giving birth and others only give birth with the assistance from their husband, parents, or other family members. During pregnancy and delivery, the majority of the community choose to be observed by the village midwife and after birth, they again have themselves and their infants checked by the village midwife. In discussions with groups of women and groups of men that are parents to under-fives, the village midwife often emerges as the first suggestion as the MCH service provider used during pregnancy and delivery, and after birth. Communities choose to use a village midwife based on their knowledge that medically, midwives can be relied upon. For example, they can be trusted to assist with risky deliveries, they have comprehensive equipment and medical supplies, they can give "suntik sehat" (pain killer and vitamin injections), and can provide referral letters to the hospital. In addition, people may choose to use a village midwife as they can pay the delivery fee in installments, even though the fees are relatively expensive compared to those of dukun beranak; afraid the midwife will not be willing to check them again if they deliver without the assistance of the village midwife; and they obtain additional services such as a birth certificate, a gift of baby equipment, and ear piercing for baby girls. vi Kelurahan, which is a village within a city, is the lowest level in the governmental organization structure. xvi The SMERU Research Institute Almost all children are immunized by the village midwife. However, some infants are not initially immunized usually because the parents are concerned that the infant will run a fever and will be fussy if they are immunized. Immunizations are mostly done at the posyandu. Although there is good community awareness about the importance of weighing infants and under-fives and most community members rely on posyandu, some still do not attend the posyandu. Reasons for this include that (1) the child does not want to go onto the scales; (2) they believe that the scales are inaccurate; (3) the child is ill; (4) they are unmotivated as the child has been fully immunized (for children over 3 years), no supplementary food is being provided, the location is not stimulating for children or there is no play area, usually the posyandu cadre collects them to take them to the posyandu, or the road is muddy; (5) the guardian is busy working or it is otherwise inconvenient, for example the mother is trading at the market, is at sea, or is harvesting; (6) no one is available to take the child, for instance, because the mother is a migrant worker and the grandmother is considered to be too old and unable to go to the posyandu; (7) parents have the false perception that a child's weight has no relation to health; (8) the mother is embarrassed to attend the posyandu because she has many children (more than five) and gives birth over the age of 45 years; and (9) there is flooding, meaning that the river is uncrossable. Although community knowledge and awareness of modern MCH services are good and the majority of the communiy have used modern MCH services, some community members still only use a dukun beranak. In addition, some women want to be assisted by the dukun beranak when delivering with the village midwife. Physical access limitations and isolation, economic access limitations, and belief in se'i in NTT are the main reasons why community members do not use modern MCH services for pre- and postnatal monitoring or for delivery. Isolation can be caused by great distances from modern MCH services; poor road conditions, including conditions where roads are difficult to pass, and there is a lack of transportation facilities and electricity; and a condition of not having a village midwife. Limited economic access is related to the high cost of delivery fees and transportation and can also lead to the need to work far from the main settlement. In addition, mothers who practice the se'i cannot go out for 40 days and are therefore inaccessable to the village midwife. Other causes for non-use of modern MCH services include that (1) the midwife is not available; (2) embarrassment or shame due to having many children or not wanting the pregnant woman's genitals to be seen by another person, (3) traditional belief in the use of dukun beranak services. Service quality does not dissuade community members from using modern MCH services, but some community members are dissatisfied with midwife services. Dissatisfaction is often related to the midwife's character, ineffective medicine, minimal experience of the midwife, difficulties in reaching the midwife, and a midwife's absence from the post. Actors at the village level that support the use of modern MCH services are village officials, the village midwife, posyandu cadres, religious figures, neighbors, spouse, extended family (mother or mother-in-law), and tokoh adat (experts in local customs). Village officials conduct socialization, apply fines, and make visits to the houses of those who do not attend posyandu sessions to make them come. Posyandu cadres are The SMERU Research Institute xvii highly active in urging the community to go to the posyandu, and together with the midwife, expain the importance of MCH. Posyandu cadres are a source of information about MCH, and help and information about general health for the community. Religious figures give support and encouragement in the use of modern MCH services. Villagers invite their neighbors and become their companions to go to posyandu, while spouse, extended family, and tokoh adat take part in influencing decisions made regarding which MCH services to use: modern or traditional. 3.2 Basic Education Services 3.2.1 Supply In terms of quantity, the existence of a primary school in each village is considered to be sufficient. However, from both the quantitative and qualitative sides, the facilities for teaching and learning activities and school infrastructure in West Java are still inadequate. The situation is more dire in NTT. In West Java, each village has two to three state primary schools, while on average, villages in NTT have only one primary school, the majority of which are private religious schools. Apart from having too few classes, many classrooms are no longer suitable to be used: the plasterboard is broken and school benches are unmaintained. Several primary schools do not have a library; if there is a library, conditions are poor and the book collection is lacking. This is also the case with visual aids and sporting equipment, which are still minimal. In NTT, there are still many schools, mainly primary schools, that only have thatched roofs, woven fibre walls, and dirt floors. In terms of quantity, there are too few junior high schools although the facilities for teaching and learning activities and school infrastructure are better than those in primary schools. State junior high schools are usually found in the subdistrict capital. In West Java, each subdistrict has more than three junior high schools, but in NTT there are usually only one or two. Great distances to junior high schools or their equivalent mean that they are unaccessible, leading to the need for schools that are closer to villages or a greater number of schools. Under normal conditions, primary schools have adequate capacities. In fact, several rural primary schools have student shortages. Problems emerge when the majority of the community living in urban areas with more than one primary school chooses a "favorite", or popular, school. Capacity limitations also occur in popular junior high schools as usually the community chooses to send their children to the junior high school in the subdistrict capital. They may do this because the school in question is a state school or because it is the popular school even though it is further away than the alternatives. In order to overcome capacity limitations, school management in several regions have issued criteria for a student selection process; for instance, that primary school students must be at least 7 years old, prospective junior high school students must have grades that adhere to the school standards, and in NTT, schools also stipulate that students must have "birth certificates". In almost all regions, children with mental disabilities are refused enrollment at primary school. xviii The SMERU Research Institute To overcome the problems of distance and isolation, in the past two years, the government and communities in NTT have established combined primary and junior high schools in one location (SD-SMP Satu Atap) and a remote class of the main school, referred to as "small primary schools" (SD Kecil). The main obstacles that popular schools and schools with damaged classrooms face are a lack of funds, which are needed to increase their capacity, a lack of teaching staff, particularly teachers of specific subjects (such as mathematics and science teachers), and the low teaching quality of teaching staff. Schools with low student numbers only receive a small amount of BOS (bantuan operasional sekolah-- Operational Assistance for Schools) funds. Since the BOS program has been in place, it has been difficult for schools to ask the community to contribute to school funding due to the understanding that BOS funds are to be used to make school free. The main obstacles that teachers face are frequently-changing curriculums, low parental supervision of their children's education and nutritional intake, as well as the difficulties that students have in absorbing theirlessons. Other obstacles that teachers face are the low prosperity level of teachers and limited available transportation to isolated areas as almost all teachers do not reside in the village in which they teach. In general, there are no obstacles to getting specific groups to send their children to primary school. However, this is not the case with the junior high school. Groups requiring special attention include (1) fishermen, (2) poor communities, (3) those living in isolated and remote areas, (4) communities that still revere the customs, (5) those who do not see the benefit in going to school and who do not see how going to school can benefit them in the future, (6) parents/guardians of girls, and (7) children with behavioral issues. Based on the results of direct observation in several schools, it is clear that teacher absenteeism is high. Several classes appeared to be empty, without a teacher, while several teachers were sitting in the teachers' room. In contrast to the direct observation, according to informants, teacher absenteeism is low, at less than 2 days per month. If a teacher is absent, it is usually because they are sick, are attending refresher courses or training, or have to attend to their family needs. Another cause for teacher absenteeism is living far from the school. Since schools have been receiving BOS funding, community participation in the provision of school facilities has tended to decline, although this is not true for isolated areas in NTT. In general, school committees at both the primary school and junior high school levels are not functioning to their full potential and generally only the committee leader has an active role. School committees are more involved in the provision of school facilities through fundraising efforts rather than in taking a role in helping to improve the quality of teaching and learning activities. The SMERU Research Institute xix 3.2.2 Demand Community awareness of the importance of sending one's child to school is good as shown in their understanding regarding the benefits of school. This has led to almost all parents sending their child to primary school and some parents sending their child to junior high school. Some parents in isolated areas in NTT are still not fully aware of the importance of sending their children to school. Some still cannot see the benefit of going to school or they cannot see that they can have a better future by going to school. These opinions are also often connected to the absence of a role model whose success is due to their education. Some communities in NTT also prioritize the customs and honor. They are willing to sell livestock for customary needs, but not for their children's school needs. A small number of parents do not send their female children to junior high school as living unchaperoned in a boarding house may reduce the girl's belis, or bride price, value. Belis is the sum of money and gifts that a bride's family requests from the groom's family when they are to be married. The higher the physical and moral "quality" of a woman, the higher the belis that the bride's family may request from the groom's family. Problems related to physical access and financial access are the main reasons for attrition and are why some parents do not send their children to junior high school. Problems related with physical access or isolation are connected to great distances between home and schools; roads that are in poor condition, hilly, and muddy, and have unbridged river crossings; a lack of junior high school facilities or equivalent nearby; and lack of transportation facilities. Financial access problems are connected to the associated school costs and the cost of everyday family needs. Associated school costs include transportation costs, purchase of books, LKS (lembar kerja siswa--students' exercise sheets), school equipment, uniforms, and snack money. Parents' inability to fulfill these high associated education expenses cause students to become embarrassed or ashamed, finally resulting in attrition. In NTT, financial access problems are also related to parents' inability to pay absenteeism fines that a child may have accumulated. Another reason for attrition from junior high school or for not continuing to junior high school is that the child does not want to go to school. Children may instead choose to help their parents who may be experiencing financial difficulties by working or earning money and they cannot see how going to school will afford them a better future. This may also be due to an inability to retain lessons, possibly caused by low nutritional intake, a lack of parental supervision, or behavioral issues. The majority of both primary school and junior high school students have never been absent from school for an extended period, and attend school as per the regulations. Generally, if a child is absent from school, it is because of being ill, having uncompleted homework, going home from the boarding house to pick up food for the following week (for junior high school students), attending to a customary ceremony or a family matter, or attending a market day. Economic reasons also cause students to be absent. During harvest time, students who do not directly help their parents in the fields are usually required to look after younger siblings or leave the village with their parents when the parents are working. In addition, financial limitations may mean that parents are unable to purchase a spare or replacement uniform for their child, so the child may truant if their only uniform is dirty or damaged. xx The SMERU Research Institute Several reasons for being absent from school are related to school or teacher quality, including inadequate school facilities and infrastructure, unstimulating or boring teaching methods, the teacher providing a poor example (for instance, the teacher often leaves class during lessons, inappropriate method of addressing or admonishing students), and the teacher often coming late to school. Actors at the village level who actively urge parents to send their children to school are village officials, school committees, and neighbors. Village officials, in particular, may issue fines to parents who do not send their children to school, may explain the importance of educating one's child to parents, and may make an effort to ensure that children who do not attend junior high school can participate in the Kejar Paket Bvii program. IV. Recommendations 1. Based on the above findings, PNPM Generasi and PKH administrators must focus on at least three main issues: (1) how both programs can respond to the main issues that frame why some people do not use modern MCH services and why some parents do not send their children to school, (2) how the programs can reach specific groups, and (3) how the participation of influential actors at the village level can be harnessed. 2. Specific groups that must be reached are isolated and remote communities, the poor, farmers and fishermen that work far from their normal residence, groups that usually use dukun beranak due to traditions and beliefs, families with many children, groups that still venerate the customs rather than the importance of school, communities that do not value the importance of educating girls, and children who are unwilling to attend school. 3. Taking note of data and information obtained in the field and the methodologies used, researchers that conduct impact assessments and program evaluations need to pay attention to the following aspects. a. Researchers should look deeper into specific topics, such as the policy of fines, various community initiatives in the provision of facilities and urging the use of modern MCH and basic education services, the role of institutions, dynamics in the relationship between officials and the community, community structure, social capital, the provision of supplementary food at posyandu and schools, and observing locations where children absent from school congregate during school hours, and gender dimensions. b. Informants should not be limited to specific informants, depending on the needs and comprehensiveness of information obtained in the field (via snowballing method), so there is clarification and triangulation of information. c. In connection with point b above, informants at each level should not only be limited to specific informants. For example, at the subdistrict level, group interviews should be held with the subdistrict head and subdistrict staff that handle or are knowledgable about MCH services, basic education, and the village context. Then, at the village level, hamlet heads, head section of welfare affairs, and others should be interviewed. d. A longer period of time (at least 10 days) is needed to conduct field research in each village. viiKejar Paket B is an education program for children who did not contiune to formal schools equivalent to junior high school. The SMERU Research Institute xxi I. INTRODUCTION 1.1 Background In mid-2007, the Government of Indonesia launched two pilot Conditional Cash Transfer (CCT) programs: the Community Conditional Cash Transfer (PNPM Generasi Sehat dan Cerdas--PNPM Generasi) and the Household Conditional Cash Transfer (Program Keluarga Harapan--PKH). These two pilot projects will be implemented in seven provinces, starting with Gorontalo and followed by West Sumatra, DKI Jakarta (Daerah Khusus Ibukota Jakarta--Special Capital Region of Jakarta), West Java, East Java, North Sulawesi, and NTT (Nusa Tenggara Timur--East Nusa Tenggara). Both projects are designed to achieve the same objectives and goals, covering five of the eight MDGs (Millennium Development Goals): to reduce poverty and hunger, to ensure universal coverage of basic education, to promote gender equality, and to reduce maternal mortality and child mortality.1 In the PNPM Generasi, block grants will be allocated to communities rather than to individual targeted households. Applying the principles of community-driven development, communities will decide how best to use the block grants to reach several education and health targets. The PNPM Generasi approach builds extensively upon the work of the Kecamatan Development Project (KDP). The PKH version applies the traditional CCT design with quarterly cash transfers to poor individual households identified through Statistics Indonesia (BPS) data. The PKH recipient households will receive regular cash transfers through the post office as long as they meet the requirements of using specified health and education services. Both CCT versions target the same 12 indicators as conditions for the routine receipt of the programs. Indicators in the health sector comprise the requirement for pregnant women to undertake prenatal checks at health institutions and to receive and take iron supplements; the requirement to deliver with the assistance of a trained health professional; the requirement for postnatal care visits for both mother and infant; the requirement for children aged 0­11 and 12­59 months to receive the complete schedule of immunizations (BCG, DPT, polio, measles, and hepatitis B) and additional immunizations as well as to be routinely weighed; and the requirement of children aged 6­11 months to receive Vitamin A. In addition, the education indicators involve the requirement for all the PKH recipients to enroll their school-aged children into primary school2 or junior high school3 and to ensure a minimum attendance rate of 85%. In the PNPM Generasi, conditionality will be placed in terms of performance-based financial incentives to villages. Village performance on the twelve indicators will be measured, compiled, and compared with other villages in the subdistrict during an inter- village meeting at the end of the project cycle. The PKH recipient households are required to visit health facilities and attend schools in order to receive their full benefits. 1The other three MDGs are combatting HIV/AIDS, malaria, and other major diseases, ensuring environmental sustainability, and developing a global partnership for development. 2In this report, the term "primary school" is used to include both sekolah dasar (SD) and madrasah ibtidaiah (MI). 3In this report, the term "junior high school" is used to include both sekolah menengah pertama (SMP) and madrasah sanawiah (MT). The SMERU Research Institute 1 Health facilities and schools will regularly report nonuse of the PKH recipient households' conditioned services to the subdistrict CCT management office. If a PKH recipient household fails to comply with the conditions after a few warnings, the cash transfers will be terminated. So that both programs' effectiveness can be better measured, both quantitative and qualitative baseline data are necessary. The data will become the basis for the evaluation of the programs' impacts in the same areas of study. The programs' effectiveness is measured by comparing conditions before and after the programs are carried out. One use of the study results will be to provide input for the implementation of the PNPM Generasi and PKH. The data and information about the supply of and demand for maternal and child health (MCH) services and basic education services will become baseline data for the future evaluation of both programs. 1.2 Study Objectives This qualitative study will be used to help understand `how' and `why' the two programs work. It will also provide the background for the social context in several program locations. The data and qualitative study results will provide a baseline that will be used to analyze change over time. Complementing the quantitative baseline survey, the CCT qualitative baseline study will probe deeper into questions of service provision and demand, placing particular emphasis on the provider-user interaction as well as contextual factors within the communities that influence access to, use of, and provision of health and education services. The specific objectives of the CCT qualitative baseline study are to 1. document the baseline conditions regarding basic health and education services specified in the CCT program, that is, the health of pregnant mothers during pregnancy, during delivery, and post-delivery, the health of children under five, as well as primary school and junior high school education; and 2. understand the underlying causes and factors that affect use and provision of services conditionedby CCTandthatare likely toinfluence projectimplementationandoutcomes. The main research questions are (1) why do some Indonesians not use basic maternal and child health services? and (2) Why do some Indonesians not send their children to primary or junior high schools? The answers to these questions will be examined from the supply side (provision of services) and the demand side (use of services). Table 1 provides the details of the main questions. 1.3 Methodology The field research of this study, which was conducted over one and half months during September­October 2007 or which in each village spanned approximately 1 week, employed a qualitative approach. The approach instruments consist of in-depth interviews with key informants, focus group discussions (FGDs) with community members using (or not using) the facilities including separate groups of men and women, 2 The SMERU Research Institute and direct observation by researchers in posyandu (pos pelayanan terpadu--integrated health service post) and both primary and junior high schools. The list of informants and FGDs of each village is presented in Appendix 1. The in-depth interviews with key informants were conducted using question guides. Between six and eight key informants were selected at the district/city (kabupaten/kota) and subdistrict (kecamatan) levels, consisting of the subdistrict head, branch heads of kindergarten and primary school offices at the subdistrict level, heads of the kindergarten and primary school suboffices at the city level, heads of the junior high school and senior high school suboffices at the district level, community health center (puskesmas--pusat kesehatan masyarakat) heads, junior high school principals, junior high school committee leaders, and a group of junior high school teachers. Approximately eight to ten informants were interviewed at the village level, consisting of the village head or lurah, community leaders, midwives, posyandu cadres, traditional birth attendants (dukun beranak), primary school principals, primary school committee heads, and a group of primary school teachers. Table 1. Research Questions Overarching research questions: 1. Why do some Indonesians not use basic maternal and child health services? 2. Why do some Indonesians not send their children to primary/junior high schools or the equivalent? Basic Education Services Maternal and Child Health (MCH) Services (Primary and Junior High Schools) Demand side Demand side Why can/do some women use basic MCH Why can/do some parents send their children to services (conditioned by CCT) and others school and others cannot/do not? cannot/do not? How different are the reasons for not sending How different are the reasons for use and non- children to school for different groups within a use of the MCH services by different groups village? within a village? Supply side Supply side 1. Why cannot/do not providers provide full 4. Why cannot/do not schools enroll and coverage of the MCH services? ensure attendance of all school-aged 2. Do providers have different problems children? reaching different groups? 5. Do providers have different problems 3. Who are these different groups and what reaching different groups? are their problems? 6. Who are these different groups and what are their problems? Other actors (e.g., village government) Other actors (e.g. village government) How do other village actors influence women to How do other village actors influence parents to use the MCH services? send their children to school? Provider-user interaction Provider-user interaction To what extent and when are users (and To what extent and when are parents involved nonusers) involved in decision-making in decision making regarding school regarding the provision of MCH services? management for primary and junior high schools? FGD were conducted using question and discussion guides. Eight FGDs were held in each village: FGDs with two groups of mothers of under-fives (one in a hamlet close to the village center or active posyandu and one in the farthest hamlet from the village center or without an active posyandu), two groups of fathers of under-fives (one in a hamlet close to the village center or active posyandu and one in the farthest hamlet from the village center or without an active posyandu), one group of mothers of primary school-aged children, one group of fathers The SMERU Research Institute 3 of primary school-aged children, one group of mothers of junior high school-aged children, and one group of fathers of junior high school-aged children. Direct observation was also used to monitor the implementation of posyandu services in 18 active posyandu and the implementation of education in 24 primary and 15 junior high schools during school hours. Several posyandu in various villages/cities could not be monitored as there were no posyandu sessions scheduled during the field visits.4 Several posyandu observations were conducted after the main fieldworks had been completed. Observation of several schools was also rescheduled considering that while the main field research was conducted, teaching activities in primary and junior high schools were disrupted for several reasons, including shortened school hours due to the start of the fasting month, examinations being held, or village or religious activities. The results of each observation were documented using a standardized observation form. The results of all interviews and FGDs were compiled into complete field notes. Field notes from each interview and FGD were organized, typed up, and expanded to answer all of the questions set forth in the question guidelines. Each FGD and interview was documented according to informant lists noting the date of the interview; the name of the note taker, interviewer, or facilitator; and the informant's name. 1.4 Sample Areas The qualitative baseline study for the two CCT programs was conducted in West Java and NTT, two of the six provinces covered in the quantitative baseline study (NTT, Gorontalo, North Sulawesi, West Java, East Java, and Jakarta). The criteria for the selection of the two provinces were based on the level of poverty and the limited time of only one and a half months that were set aside for the field research. Between one and three districts/cities were chosen in each province to represent the PNPM Generasi and PKH, both treatment and control, using the same selection criteria of poverty levels and ease of access. In West Java Province, the two districts chosen were Sumedang and Cirebon. Sumedang was chosen to represent a region that is planned to host the PNPM Generasi and which has a relatively low poverty rate, while Cirebon was chosen to represent a region planned to host the PKH and which has a relatively high poverty rate. In NTT Province, the two districts and one city chosen were North Central Timor (TTU--Timor Tengah Utara) District, South Central Timor (TTS--Timor Tengah Selatan) Province, and the City of Kupang. TTU was chosen to represent a rural area which is planned to host the PNPM Generasi and has a high poverty rate. TTS was chosen to represent a rural area which is planned to host the PKH and has a high poverty rate. Kupang was chosen to represent an urban area that is also planned to host the PKH and has a relatively low poverty rate. One to three subdistricts were then chosen for each district/city after the researchers had obtained sufficient data and information from the health offices and education offices at the district/city level. The subdistricts were chosen based on a combination of data from both sectors, the list of subdistricts from the quantitative survey, regional spread, and 4 Posyandu sessions are usually only held once a month. 4 The SMERU Research Institute access to the district/city capital. Data from the district level included the school discontinuation rates/levels of those not continuing to junior high school, gross/net enrollment rates (angka partisipasi kasar/murni/APK/APM), maternal mortality rates, the prevalence of malnutrition, the prevalence of dukun beranak, and service coverage. In West Java, five rural subdistricts (Rancakalong, Buahdua, and Darmaraja in Sumedang; Gegesik Kulon and Susukan in Cirebon) and two subdistricts with urban characteristics (Mundu and Gunung Jati,5 both in Cirebon) were chosen. In NTT, five rural subdistricts (North Biboki, Insana, and East Miomaffo in TTU; Kie and Batu Putih in TTS) and two urban subdistricts (Alak dan Maulaffa in Kupang City) were chosen. Maps of the selected districts and subdistricts are presented in Appendices 2­6. Table 2. Research Locations No. District/City Subdistrict Category Village/ Kelurahan West Java 1 Sumedang PNPM Generasi/ Nagarawangi Rancakalong Treatment/Rural 2 Pamekaran 2004 poverty rate: Non-Incentivized* 3 11.74% PNPM Generasi/ Buahdua Buahdua Treatment/Rural 4 Bojongloa Incentivized* 5 PNPM Generasi/ Sukaratu Darmaraja 6 Control/ Rural Neglasari 7 Cirebon Gegesik Kulon Gegesik PKH/Treatment/Rural 8 Jagapura Kidul 9 2004 poverty rate: Susukan Susukan PKH/Control/Rural 10 16.59% Tangkil 11 Mundu PKH/Control/Urban Mundu Pesisir Gunung Jati/ 12 PKH/Treatment/Urban Mertasinga North Cirebon East Nusa Tenggara (NTT) 13 North Central Timor PNPM Generasi/ Taunbaen (TTU) North Biboki Treatment/Rural 14 Hauteas Non-Incentivized* 15 2004 poverty rate: PNPM Generasi/ Sekon 30.65% Insana Treatment/Rural 16 Susulaku Incentivized* 17 Oenenu East Miomaffo PNPM Generasi/ Control/Rural 18 Kuanek 19 South Central Timor Oenay Kie PKHTreatment/Rural 20 (TTS) Falas 21 2004 poverty rate: Boentuka Batu Putih PKH/Control/Rural 22 37.38% Oehela 23 City of Kupang Alak PKH/Treatment/Urban Fatufetto 2004 poverty rate: 24 Maulaffa PKH/Control/Urban Naikolan 10.65% Note: *The difference between non-incentivized and incentivized lies in the distribution of the grant amounts to villages in the second year, with the incentivized kecamatan distributing a fifth of the grant to villages according to the villages' first year achievements in the 12 indicators. This will test the effectiveness of conditioning block grants to performance in improving the performance of the communities and thus the overall benefit of the project. 5 Gunung Jati was previously named North Cirebon. The SMERU Research Institute 5 Two villages/kelurahan6 in each subdistrict were then chosen in order to see the differences in access to health and education facilities based on information and data obtained at the subdistrict level from subdistrict officials, kindergarten and primary education branch offices, and puskesmas using the same criteria as those at the district/city level. Distance from the puskesmas and level of posyandu activity were additional criteria used to determine the sample villages/kelurahan and the posyandu schedule was also taken into consideration. Based on the above criteria, a total of 24 villages/kelurahan were chosen for the study (Table 2). In each village/kelurahan, two areas, usually hamlets (dusun), were chosen as study sites at the community level: one close to and one far from the village center and MCH services, or one site close to an active posyandu and one site without an active posyandu. Because almost all posyandu are active, apart from considering a hamlet's distance from the village center and MCH services, sites were chosen based on the coverage of the posyandu (one with high coverage and one with low coverage). FGD participants for the discussion of MCH were usually chosen from the list of posyandu participants using several criteria that excluded village officials, civil servants, teachers, migrants (perantau), and those difficult to invite to the discussion. Efforts were made to ensure that pregnant women were among the participants. For the discussions of primary and junior high schools, community members with children of primary school and junior high school ages were chosen, with the same exclusions as for the MCH FGDs. Efforts were also made to include parents of children who had withdrawn from school or had not continued their education. In most cases, information obtained from posyandu cadres was usually used to determine FGD participants, as the cadres knew the majority of community members. If there were more than one primary school or junior high school in a village/kelurahan, the school of each level receiving the most children from the selected hamlet was chosen for observation. In the majority of cases, the schools were selected after the FGDs for primary and junior high schools were held. 1.5 Report Structure This report is divided into five chapters. Chapter 1 provides the background to why the research was conducted and what it will be used for, the study objectives, methodology and approach used in the research, and the report structure. Chapter 2 presents the general characteristics of the sample areas in order to provide readers with an understanding of the studied areas in order to connect the conditions with the research findings. Chapter 3 is a synthesis of supply of and demand for MCH services, while Chapter 4 is a synthesis of supply of and demand for basic education services. Chapter 5 presents conclusions from the findings of the entire study and recommendations for the implementation and results of the PNPM Generasi dan PKH. The conclusions and recommendations will also elucidate the lessons that can be drawn in relation to the research methodology used, with the aim of improving the research instruments used in future program evaluations. 6Kelurahan, which is a village within a city, is the lowest level in the governmental organization structure. 6 The SMERU Research Institute II. SAMPLE REGION CHARACTERISTICS As outlined in the introductory chapter and in accordance with the selection framework for sample locations in rural areas, two sample villages were chosen in each selected subdistrict: one village easily accessible and the other relatively difficult to access. The level of accessibility was not always measured in terms of the villages' distance from the subdistrict center; rather, it also depended on road conditions and the availability of public transportation from and to the sample villages. The subdistrict center was used as a criterion considering that this is usually where MCH services (puskesmas) and basic education services (at the SMP level) are generally located. In urban areas, particularly in Cirebon District, West Java, sample locations were selected based on the consideration that the chosen villages were characterized as urban and were also coastal villages. Two sample subdistricts directly bordering the region of Cirebon City were chosen as representatives of urban areas in Cirebon District. From each subdistrict, one coastal village characterized as the most urban in the subdistrict was chosen. Also, in Kupang City, NTT, the most densely populated kelurahan was chosen from each of the two sample subdistricts, with the additional consideration that both kelurahan must have the highest number of dukun beranak. 2.1 Research Locations All sample villages in Sumedang and Cirebon districts are easily reached; the farthest village is only located 6­7 kilometers (km) from the subdistrict center. In this study, the rural villages characterized as easily accessible are located in the subdistrict center or villages directly bordering the subdistrict center. The villages falling under this category consist of Nagarawangi village in Rancakalong Subdistrict, Buahdua village in Buahdua Subdistrict, Sukaratu village in Darmaraja Subdistrict, Gegesik Kulon village in Gegesik Subdistrict, and Susukan village in Susukan Subdistrict. The communities in these villages can easily reach MCH services and basic education facilities, either those located in the local subdistrict or those in other subdistricts or the district capital, or other cities. The main district road serviced by the intercity public buses travelling between subdistricts and districts/cities also passes the villages. Sukaratu village is serviced by the alternative main road connecting Tasikmalaya City and Jakarta, while both villages in Gegesik Subdistrict are also passed by the district road serviced by the public buses connecting Indramayu and Cirebon City via Arjawinangun. Moreover, in Cirebon District, Mertasinga village in Gunung Jati Subdistrict and Mundu Pesisir village in Mundu Subdistrict are both located along the busy northern coastal road and close to Cirebon City, and so have quite a selection of available transportation facilities. In both the selected districts in West Java, the sample villages that are relatively difficult to access are only between 2 and 7 kilometers from the subdistrict center. However, it is still difficult to access public transport in two villages: Pamekaran village in Rancakalong Subdistrict, Sumedang; and Tangkil village in Susukan Subdistrict, Cirebon. In Pamekaran village, public transportation is unable to enter the village and is only operational at certain times, while in Tangkil village, especially the farthest hamlet, the community must walk or use a motorcycle taxi (ojek) costing around Rp5,000 for each journey to reach the main district road serviced by the public bus. The SMERU Research Institute 7 As in West Java, in TTU and TTS districts, the majority of sample villages that are easily reached are relatively close to the subdistrict center. In particular, Boentuka village in Batu Putih Subdistrict is on the main Kupang­Soe road. For the sample villages that are relatively difficult to access like Taunbaen village in North Biboki Subdistrict, Susulaku village in Insana Subdistrict, Kuanek village in East Miomaffo Subdistrict, Falas village in Kie Subdistrict, and Oehela village in Batu Putih Subdistrict, the majority of roads are damaged, rocky, and winding. During the wet season, these roads become muddy and slippery, and vehicles cannot pass. Access to all sample villages in West Java and NTT is presented in Appendix 7. From the regional topography perspective, all villages in Sumedang District are located in highlands and most border other villages from the same subdistrict. However, there are also villages that directly border forest or mountain regions or that border a different district. Only Sukaratu village in Darmaraja Subdistrict has a relatively flat area. Furthermore, in Buahdua Subdistrict, both sample villages are passed by several rivers. All villages in TTU and TTS districts are also located in hilly highlands. In contrast, in Cirebon District, sample villages are generally located in low-lying areas, especially Mertasinga and Mundu Pesisir villages that are coastal villages, are bordered by a river that flows to the Java Sea, and directly border the area of Cirebon City. Two kelurahan in Kupang City are also in low-lying areas that are relatively close to the beach. As shown in Appendix 8, administratively, the sample villages in West Java consist of three to five hamlets. The majority of the villages consist of 8 RW,7 with a range of between 5 and 14 RW, and all villages have more than 20 RT,8 In NTT, there are generally fewer hamlets, RW, and RT in each village than there are in the villages in West Java. 2.2 Natural and Economic Resources The agricultural sector has become the `pillar of life' for the majority of communities in rural areas, both in West Java and NTT. Most communities in West Java are more reliant upon the subsector of food crops that are supported by fertile land conditions, while in NTT, dryland food crops are favored due to the less supportive land conditions in the region. The majority of NTT communities are also reliant on annual or tree crops. Apart from the unfertile land, rainfall is also very low. As a result, communities in NTT are also reliant on the livestock industry and estate crops. The majority of communities in all sample villages in Sumedang District work as lowland rice field laborers. This work is not only done by men; the women are also involved, mainly during the planting, clearing, and harvest times. This is reflected in the proportion of land use which is dominated by agricultural fields, mainly lowland rice fields. Apart from rice, some communities work on secondary crops such as corn, peanuts, and cassava as well as vegetables such as long beans, eggplant, cucumber, and chili as alternate crops. In Bojongloa village, Buahdua Subdistrict, some also have estate crops such as coconut, coffee, clove, pepper, and vanilla bean. Apart from that, they also plant fruits such as mango, papaya, and rambutan although in a limited scale and only regarded as "back yard" 7 RW is a unit of local administration consisting of several RT (neighborhood units). 8 RT, or a neighborhood unit, is the smallest unit of local administration consisting of a number of households. 8 The SMERU Research Institute crops. Other forms of work often undertaken by sample village communities include agricultural laborers, traders (kiosks or trading in Jakarta), tradespeople (builders, carpenters), motorcycle taxi operators, livestock farmers, laborers or other private employees, and civil servants (including retirees). In addition, child labor was found in several villages, with the children mainly working as laborers in home industries, motorcycle taxi operators, public transport conductors, domestic workers, and traders. There are more community members working as farm laborers in the majority of sample villages in Cirebon District, when in fact Gegesik Subdistrict is known as the rice barn (lumbung beras) of Cirebon District. As a matter of fact, lowland rice fields dominate the village area. The coastal communities in Mundu Pesisir and Mertasinga villages are mainly fishermen. Other people in Cirebon work as traders, industrial laborers, tradespeople (builders, carpenters), motorcycle or pedicab operators, drivers, and, specifically for many women, migrant workers in Saudi Arabia. In TTU and TTS districts, the majority of communities work not only as farmers planting corn, sweet potato, cassava, peanut, and upland rice, but also as livestock farmers and plantation pickers for crops such as tamarind, areca nut, cashew nut, coconut, and candlenut. Other than that, some also work as traders, motorcycle taxi operators, or civil servants. The majority of community members in the two sample kelurahan in Kupang City work in the services sector as traders, laborers, civil servants, or retirees, with the exception of Fatufetto village, where some also work as fishermen. Housing in Sumedang District are already dominated by permanent buildings, with only a small proportion of semipermanent rumah panggung (a traditional, raised, timber and bamboo sheeting house) remaining. In Cirebon District, housing is also dominated by permanent buildings, except in Jagapura Kidul village, Gegesik Subdistrict, which is still dominated by semipermanent and temporary housing. In villages where some community members work as migrant workers, a fair number of permanent houses have recently been built or are under construction, using the resulting wages. In contrast, in the sample villages in TTU, the majority of houses only have thatched roofs made from reed, walls made from sheets of woven dry palm leaves, and dirt floors. However, in the two kelurahan in Kupang City, housing is dominated by permanent houses. In West Java, electricity from the State Electricity Enterprise (PLN--Perusahaan Listrik Negara) is the main source of lighting in all sample villages, while in NTT not all villages are reached by electricity. Several villages in NTT, like Taunbaen village in North Biboki Subdistrict, both villages in East Miomaffo Subdistrict, and both villages in Kie Subdistrict still use oil lamps and only a small minority have used generators or solar energy. In the villages serviced by electricity, only some community members are able to access it and it only supplies a limited amount of power. Some of the villages in Sumedang District pipe clean water to houses, which is made possible through the community's initiative, while some other community members still use pump wells or dug wells. The majority of sample villages in Cirebon District also experience difficulty obtaining clean water. They cannot use ground water due to intrusion from sea water, so some are forced to buy clean water for drinking. Communities in NTT face even more serious clean water scarcity. Clean water is scarce in the dry season. In Oehela village, Batu Putih Subdistrict, the people must walk for about 30 minutes to reach a source of clean water. The SMERU Research Institute 9 In several villages in West Java, mainly villages located in the subdistrict center, the community can easily access economic facilities such as the market and shops (Buahdua, Susukan, and Mundu Pesisir villages). Apart from that, several villages are home to manufacturing industries. For example, In Nagarawangi village, Rancakalong Subdistrict, there are clothing, furniture, and palm-fibre broom household industries, while Gegesik Kulon village is also home to snackfood processing industry and the waste collection and trading business is growing. In Mundu Pesisir village, there are both large- and small- scale manufacturing industries. 2.3 Populations The total population and number of households in the sample villages in Sumedang District are smaller than those in the sample villages in Cirebon District. This is reflected by both the number of household members in each household, which averages at around three household members per household in the sample villages in Sumedang District, and more than three household members per household in Cirebon District; in fact, in Mertasinga village, Gunung Jati Subdistrict, there are five household members per household. In terms of population density, sample villages in Sumedang District generally have less than 900 people per square kilometer (people/km2); in fact, Bojongloa village only has around 600 people/km2. However, there is an exception in Sukaratu village, Darmaraja Subdistrict, which has a population density reaching 1,979 people/km2, which exceeds population densities in the sample villages in Cirebon District. The population number and density in sample villages in TTU and TTS districts are certainly far lower than those in the sample villages in West Java. There is a large difference in the population densities in the two urban villages in Cirebon District: In Mundu Pesisir village, it is around 3,784 people/km2, while in Mertasinga village, it is far higher, at 8,231 people/km2. In the two sample kelurahan in Kupang City, it is even higher, reaching more than 8,400 people/km2, as shown in Appendix 9. In terms of the ratio of men to women, in the villages in Sumedang District, women seem to outnumber men, except in Bojongloa village, Buahdua Subdistrict, and Neglasari village, Darmaraja Subdistrict. In Cirebon District, the reverse is the case; in four of the six sample villages, there are more men than women. In the sample villages in TTU and TTS districts, there also tend to be more men than women, with the exception of Oehela village. In Kelurahan Fatufetto, there are equal proportions of men to women, while in Kelurahan Naikolan, there are more women than men. The majority of the population in both West Java and NTT only enjoy a primary school education. In fact, in both coastal villages in Cirebon District particularly, many of the FGD participants did not graduate from primary school; they generally discontinued their schooling in grades four and five. 10 The SMERU Research Institute 2.4 Community Groups and Institutions Standard institutions at the village/kelurahan level should consist of: - BPD (badan permusyawaratan desa--village people's consultative assembly), which monitors the performance of village officials; - LPM (Lembaga Pemberdayaan Masyarakat--Institute for the Empowerment of Rural Community), which helps village/kelurahan heads to implement village development; - Karang taruna, which coordinates various youth activities such as arts and sports; - PKK (Program Kesejahteraan Keluarga--Family Welfare Program), headed by the wife of the village/kelurahan head), which coordinates women's activities; and - Kelompok Tani (Farmers Group), which coordinates farmers' activities (specifically in the sample villages in West Java, it is known as Mitra Cai (Ulu-Ulu), which is responsible for the distribution of irrigation water). All of the above village organizations are not always found or mentioned in each sample village, either in West Java or in NTT. Moreover, the performance of each organization differs between the sample villages, as seen in Appendix 10. The presence of these various formal institutions has not yet been fully utilized in efforts to improve the coverage of health and basic education services. Nevertheless, in several villages, organizations such as PKK have been involved in various activities encompassing MCH services, like in Darmaraja Subdistrict. In this subdistrict, PKK is highly supportive of posyandu activities and always coordinates with village midwives, including in their activities to get their village to reach the status of a Desa Siaga.9 The same is true for the existence of karang taruna, which is particularly beneficial for and relevant to various health- and education-related activities at the village level. In several sample villages in NTT, the community worked together with the village board and the church on an initiative to build various support facilities for schools although the conditions tend to be limited. For example, in two villages in North Biboki Subdistrict, a small primary school was built in an isolated hamlet to increase the primary school's capacity and to ease access to school. A similar thing has occurred in Oehela village, Batu Putih Subdistrict, where the community and local village officials had taken the initiative to build a kindergarten. In two villages in East Miomaffo Subdistrict, the community had built a dormitory for SMP students in order to overcome the problem of distance, and therefore, the students do not need to go to and fro between home and school each day. Apart from formal institutions, organizations or community groups focused on religious, economic, and social activities, including customary institutions, were found in several sample villages. It is estimated that in every village in West Java, there are religion-based community groups such as kelompok pengajian (Koran reciting groups) and majelis taklim (forums where Islamic sermons are given). The same can be said for NTT, which has thriving church community activities. In North Biboki and East Miomaffo subdistricts, there is a youth organization similar to karang taruna called Mudika (Muda-mudi Katolik, or Catholic Youth). Particularly in the village of Jagapura Kidul, Gegesik Subdistrict, there are quite many Islamic education foundations which play a large role in the provision of basic and further education facilities. 9Desa Siaga, or alert village, is a village which has successfully met a number of specific maternal health criteria, such as an existence of a blood donor group to ensure supply in an emergency, in the framework of getting the entire community to be more involved in safe maternity. The SMERU Research Institute 11 2.5 Health and Education Facilities 2.5.1 Health Facilities MCH service facilities available at the village/kelurahan and subdistrict levels are dominated by government health services such as puskesmas, secondary puskesmas (pustu), or mobile puskesmas (pusling), and polindes (pos persalinan desa--village maternity post) with the village midwife, followed by privately practicing midwives and posyandu activities. In emergencies, if the midwife and puskesmas are unable to handle a complicated delivery, the patient will be referred to the regional public hospital (RSUD--rumah sakit umum daerah) owned by the local government and generally located in the district capital. In almost all sample villages, there is a polindes managed by a village midwife. In addition, in each subdistrict, there is a puskesmas and in several villages, there is also a pustu. For isolated regions in NTT, puskesmas also provide a mobile facility (a pusling) which services the community three times per week. Posyandu are found in almost every hamlet, or even every RW, and provide routine services once each month. The availability of MCH service facilities in the sample villages can be seen in Appendix 11. Each posyandu is usually managed by three to five cadres. In Sumedang District, posyandu activities are scheduled for a specific date each month, with the exception of Sukaratu village, Darmaraja Subdistrict. Because the local village midwife is currently undertaking further midwifery studies (D310 Kebidanan), the posyandu activities are scheduled for each Thursday when the midwife can attend. In Cirebon District, posyandu activities are generally scheduled for particular days and weeks, but some are more flexible, for example Mertasinga village, depending on the activities of the local women. In NTT, specifically in TTU and TTS provinces, posyandu activities are scheduled for specific dates. In West Java, some posyandu activities are held at their own post, but some others use the house of a cadre, a community figure, the village office, polindes or pustu, or even the puskesmas. In NTT, some posyandu activities are conducted in the village lopo,11 the polindes, or a cadre's house like in Falas village. In Boentuka and Oehela villages, Batu Putih Subdistrict, and Sekon village, Insana Subdistrict, all posyandu activities in each village are based in the one polindes and are conducted simultaneously. This way, the village midwife can more easily coordinate the activities. However, a negative consequence is that the community must travel a reasonably great distance to go to the specific polindes. In West Java, although not all villages have a polindes, midwife services can be accessed very easily considering that generally the midwife stays or lives in the village or close to the village to which they are assigned. Almost all village midwives also open a practice outside the health office's working hours. Consequently, the community can also easily access the village midwife or private midwife services. Nevertheless, dukun beranak services are still used by a small proportion of the community in both Sumedang and Cirebon districts. 10 A three-year diploma program 11 Lopo is a building native to NTT (Kabupaten TTU) which is circular, made up of four wooden (nowadays, also cement) pillars and a roof made from dry leaves. This structure is usually situated in front of a community member's house and functions as a place for family meetings or customary ceremonies, or for receiving guests. The locals usually weave in lopo as well. The lopo has such a cool atmosphere that villagers often take a rest in the structure. 12 The SMERU Research Institute In contrast to the conditions in West Java, in NTT, specifically in the villages in TTU and TTS districts, village midwife practices are not available because the people in the community cannot afford it. In Kupang City, although it is relatively easy for the community to access midwife practices, the use of dukun beranak services is still quite high. Communities in the sample villages in West Java can access puskesmas or pustu relatively easily, and in fact, some subdistricts in the province have two puskesmas, like Gegesik Subdistrict in Cirebon. Several sample villages in West Java host the puskesmas, such as Buahdua village in Sumedang District and Susukan and Mertasinga villages in Cirebon District. Apart from that, some villages have a pustu, like Pamekaran village in Sumedang District. For the other sample villages, while the puskesmas or pustu is located outside the village, it is still easy to access due to the available public transportation services. In NTT, only Taunbaen village in North Biboki Subdistrict has a pustu. The communities in other villages must access the puskesmas or pustu outside the village. This does not occur in urban areas. Communities in both kelurahan in Kupang City can reach the puskesmas relatively easily; Kelurahan Fatufetto even has a pustu. 2.5.2 Education Facilities Primary school facilities are available in all sample villages in both West Java and NTT, while the majority of junior high school facilities are only found in subdistrict centers. The government still has a dominant role in the provision of school facilities at the primary and junior high schools; however, in several regions, the role of private groups is also no less important in broadening the scope of basic education services. In several villages in NTT, there are only private religious primary schools, such as Catholic primary schools (SDK-- sekolah dasar Katolik). In West Java, each sample village has two to three primary schools, while in NTT, each sample village/kelurahan has one to three primary schools. In villages/kelurahan with more than one primary school, the schools are scattered over several hamlets, so the communities can easily access the closest school (Appendix 12). In TTU District, in an effort to move school facilities closer to the community, principals and teachers cooperated with village officials and the local community to build an additional class in the most remote hamlet. In Taunbaen village, for example, a "small class" (SD Kecil) which services grade one to grade three students was opened, while in Hauteas village, two "far classes" (kelas jauh) have been built. Some sample villages have a junior high school, while the communities in other villages must access them outside the village. In West Java, it is relatively easy for the community to access junior high schools. They are also able to reach other schools outside the subdistrict region. For example, the community in Tangkil village can access the junior high schools in Caringin and Arjawinangun subdistricts. The community in Mundu Pesisir village can also access the junior high school in Arjawinangun Subdistrict or Cirebon City. In Pamekaran village, Sumedang District, it is not difficult to reach SMPN (Sekolah Menengah Pertama Negeri) I (State Junior High School I) Rancakalong, a favorite school, from the village, but because there is no four-wheeled public transportation servicing the village, only motorcycle taxi services, transportation costs are expensive and students must walk. The SMERU Research Institute 13 The availability of private religious schools also provides an additional choice for communities. Such schools have a more prominent role in Cirebon District. In Gegesik and Mundu subdistricts, for example, there are several Islamic primary schools (madrasah ibtidaiah--MI) and Islamic junior high schools (madrasah sanawiah--MTs), as well as several other primary and junior high schools that have been established under the name of a particular Islamic foundation. 14 The SMERU Research Institute III. AVAILABILITY AND USE OF MATERNAL AND CHILD HEALTH SERVICES The results of the latest monitoring of Indonesia's performance towards achieving the MDGs in 2007 (UNDP12-Bappenas13 2007) show that the indicators for reaching goal number 4, a reduction in child mortality rates, have improved. This is shown by the infant mortality rate (IMR), which has experienced a reduction from 57 (57 deaths per 1,000 live births) in 1994 to 35 in 2002­2003, and the under-five mortality rate (U5MR), which in the same years has fallen from 81 (81 deaths per 1,000 live births) to 46. The province of NTT has the third highest IMR in Indonesia after West Nusa Tenggara (NTB--Nusa Tenggara Barat) and Gorontalo at 46, while West Java has the ninth highest IMR at 37. In addition, the indicators for achieving goal number 5, the improvement of maternal health, have also slightly improved. The maternal mortality rate (MMR) has fallen from 390 (390 deaths per 100,000 live births) in 1994 to 307 deaths in 2002­2003, while the proportion of deliveries assisted by skilled birth attendants in 2006 reached 72.41% (UNDP-Bappenas 2007). Although this shows a tendency to improve, each year around 20,000 women still die as a result of pregnancy or childbirth complications which cannot yet be completely handled. With such conditions, it is predicted that the MDGs' 2015 targets cannot be met. The direct causes of maternal deaths are haemmorage (30%), eclampsia or poisoning in pregnancy (25%), long delivery (5%), abortion complications (5%), and infections (12%). The risk of death can increase if the mother is suffering from anemia or chronic fatigue, or has an infectious disease (UNDP-Bappenas 2007). Data for the performance indicators for the decline in IMR and the increase in maternal health is presented in Table 3. Table 3. Maternal Mortality, Proportion of Deliveries Assisted by a Skilled Birth Attendant, Infant Mortality, and Under-five Mortality Maternal Proportion of Infant Mortality Under-five Mortality Rate Deliveries Rate ­ IMR Mortality Rates ­ ­ MMR Assisted by a (deaths per 1,000 U5MR (deaths per Skilled Birth live births) (deaths per 1,000 100,000 live Attendant live births) births) (%) Indonesia 1992 n.a. n.a. 68 97 1994 390 n.a. 57 81 1997 n.a. n.a. 46 n.a. 2002­2003 307 n.a. 35 46 2005 n.a. n.a. n.a. 40 Projection for 2015* 163 n.a. n.a. n.a. 2006 n.a. 72.41 n.a. n.a. Source: Laporan Pencapaian MDGs Indonesia 2007 [Report on Indonesia's Achievement of the MDGs in 2007] (UNDP-Bappenas 2007: 49­59) Note: n.a. = data not available 12 United Nations Development Programme 13 Badan Perencanaan dan Pembangunan Nasional (the National Planning and Development Board) The SMERU Research Institute 15 The above data shows that the availability (supply) and use (demand) of MCH services still face a number of problems, so service coverage is not yet optimal. The following sections will explain the current conditions of supply of and demand for MCH services. 3.1 Supply, Conditions, and Coverage of Basic Maternal and Child Health Services It cannot be denied that community demand for modern MCH services is highly influenced by the supply of services at the village level. With the availaibility of MCH services located close to community residences, the community becomes more aware of the existence of the facilities and can be expected to use them. For years, the government has endeavored to fulfill community need for MCH services, by providing village midwives, polindes, and pustu at the village level, with the expectation that these facilities will easily reach the community. In fact, these days the local governments (puskesmas and village administrations) in several areas in West Java that are remote from polindes have undertaken an initiative to implement treatment posts--several of them reaching the RT level. However, these MCH facilities are still insufficient, particularly in isolated regions. Scarcity of modern MCH workers in these regions is one of the causes why the communities use traditional MCH service facilities. 3.1.1 Supply of Modern MCH Service Facilities There is a sufficient supply of modern MCH facilities in areas with easy access, but in areas far from reach, supply is still lacking. Village midwives, polindes, and posyandu are available. In several villages in West Java, communities can easily access privately practicing midwives, pustu, and puskesmas. In NTT, however, although there is a puskesmas in each subdistrict and a pustu in several subdistricts, these facilities are unpopular with communities in several areas because they are too distant. In urban areas, both in West Java and NTT, communities can access obstetricians. They can also access the closest public hospital in the event that complications arise during either pregnancy or the delivery process. For isolated areas far from the reach of modern MCH services, additional health facilities are still required, as stated by one village head in Rancakalong, Sumedang, West Java, "Health facilities are still considered to be lacking because we are too far from facilities and equipment is lacking. " In NTT, particularly in isolated areas difficult to access, not all village midwives are willing to live in the village, and consequently, polindes are not operational. For example, in East Miomaffo Subdistrict, TTU, out of the 11 villages that have a village midwife, only 6 of the midwives live in the village. While the other five village midwives do operate the polindes each day, they do not actually reside in the village. The midwives in Kuanek and Oenenu villages, East Miomaffo, TTU live in Kefamanu, the district capital of TTU, due to family obligations. Another example is found in Sekon village, Insana, TTU. While the village midwife lives in the village, she is often not there as she is caring for her parents who live in another village. This makes it difficult for the community to access health services in the evening or in an emergency. They must instead walk for kilometers along a steep road to the modern MCH services in a neighboring village. If it rains, the road becomes muddy and slippery. The lack of transportation facilities means that the community must pay a significant fare for a motorcycle taxi. 16 The SMERU Research Institute Since 2002, Falas village in Kie Subdistrict, TTS, NTT has not had a village midwife. The community is only serviced by the head nurse during posyandu and pusling services, while the coordinating midwife or officers from Kie Puskesmas only occasionally come to observe. As there is no village midwife, the polindes is also inactive. A lack of water has also meant that a village midwife is not prepared to live in the polindes or the village. To date, there has been no replacement midwife in the village. In NTT, broad working territories mean that village midwives cannot service the entire community, even if the village midwife resides in the village. Some hamlets are remote, located up to 10 kilometers from the village midwife or the polindes. Poor road conditions (rocky, steep, and slippery in the event of rain), lack of transportation, and a lack of electricity make it more difficult for midwives to go out to the community or for the community to go to the midwife. Occasionally, a midwife must make house calls and be forced to "abandon" their assignment at the polindes. This is explained by a nurse who acts as a midwife in Hauteas village, North Biboki, TTU, NTT: "The fact that a midwife is not at the post does not mean that the midwife has left the village. But the size of the village and the number of patients that we must manage in various locations mean that we are sometimes not at the polindes." Village midwife services generally involve prenatal checkups, delivery assistance, administering immunizations to infants, administering "suntik sehat" (pain killer and vitamin injections) to women after delivery, controlling maternal and child health, providing information to mothers and prospective mothers about MCH, providing family planning services, treating malnutrition, and treating sick children. While conducting treatment, for instance administering immunizations, the midwife usually explains the immunization timetable to mothers. The entire village falls under the territory of the village midwife and polindes. Polindes services are limited to the hours between 07:00 and 14:00, but the midwives residing the village are usually on call 24 hours a day. There are posyandu in every village in West Java; they even exist in every hamlet. Almost all are active and well-managed by the posyandu cadres. Posyandu are the spearheads of MCH services at the community level. They are managed by midwives together with the posyandu cadres (consisting of three to five people) who services to note, weigh, measure, immunize, and provide information (often referred to as the "lima meja", or "five-table", services). The normal process of posyandu activities will be disrupted if there are an insufficient number of cadres. This is the case in Tangkil village, Cirebon, which only has nine cadres who actively service six posyandu. As a result, two posyandu do not have any cadres, instead relying on a midwife and a puskesmas officer. To date, posyandu cadres play a highly central role, both in the provision of modern MCH services and in community life. They are usually active in various village activities together with the village head and village midwife. For communities, posyandu cadres are a source of knowledge and assistance related to maternal and child health. Posyandu cadres understand far more of the situation and real conditions of the community in the village and in their hamlet. The majority are women, except in NTT where there are large numbers of male posyandu cadres, for instance in Falas and Oenay villages in TTS. The posyandu cadres are the first to know who is pregnant, which family has under-fives, which under-fives have been immunized, what the nutritional status of under-fives is, where the people live, what the household size is, what the economic status of the The SMERU Research Institute 17 household is, who is healthy and who is sick, and also who has children of primary--or junior high--school ages, or which child does not attend school.14 Unfortunately, village administrations do not fully appreciate the presence of posyandu cadres whose workload is heavy starting from servicing patients in the posyandu, observing community health conditions, and providing information to completing administrative tasks. This affects community members' willingness to become a posyandu cadre. Apart from the main cadre or the cadre leader, there is a high turnover among other posyandu cadres. In Susukan and Tangkil villages, Cirebon, for instance, many posyandu cadres had to leave their assignments due to economic needs; one of the alternatives is by becoming an overseas migrant worker after the monetary crisis. Since then, the posyandu in those villages are only managed by two or three posyandu cadres, less than what is required to meet the standard of a madya (medium) and mandiri (self- sufficient) posyandu. The lack of appreciation for posyandu cadres is not only reflected in the amount of incentives they are provided with--at most only Rp120,000 per year15--but also by the training they receive. Although they have a central position in increasing the level of community health, not all cadres receive training. In fact, in various regions, no more than 25% of posyandu cadres have received training, as acknowledged by the head (male) of one Puskesmas in Kupang. Usually only the coordinating posyandu cadres receive training, both at the village and hamlet levels. It is expected that the trained coordinating cadres will pass their knowledge on to the other cadres who have not received training. The training provided to cadres is generally not standardized and differs in each region. Materials usually convered are related to the health of pregnant women or new mothers, the implementation of posyandu services, nutrition, immunizations and weighing, family planning, prevention of certain diseases such as vomiting and diarrhea, dengue fever, and malaria, and environmental health. Puskesmas are unpopular in NTT due to the obstacle of physical accesss. Although there are puskesmas in every subdistrict, they are not too popular for communities in the majority of rural areas in NTT. Distant puskesmas (3­15 kilometers away) will only be accessed in very urgent situations, for example, if a person needs treatment with more comprehensive facilities or because the midwife referred them to the puskesmas. There are also some hamlets, however, that are closer to the puskesmas in a neighboring village than to the polindes in their local village. 3.1.2 Modern MCH Facilities and Infrastructure Although midwives have provided health services to the community with the equipment that is available, the equipment is felt to be lacking. In general, the village midwife possesses a "midwife kit", infusion equipment, and a blood pressure monitor. A midwife (Rancakalong, Sumedang, West Java) states that she "feels that the equipment for either private practice or in the posyandu are currently inadequate, that is, 14 Because of the posyandu cadres' level of knowledge, researchers usually rely on them in FGD preparation, including in selecting the samples that will be invited to the FGDs. Before determining who will be invited, by using the posyandu register usually kept by a cadre, researchers will ask about several criteria such as which posyandu client is currently pregnant, is not a civil servant, is poor, and is not currently away from the village. 15 In general, posyandu cadres receive Rp5,000­10,000 per posyandu session. 18 The SMERU Research Institute there is no laboratory, no modern equipment for detecting the heart beat, and still many more." Village midwives in urban areas have more comprehensive equipment, such as ultrasound equipment to monitor the condition of infants. The quality of polindes facilities and infrastructure varies. Polindes are usually located at the residence of the village midwife and are close to the village office. Some polindes buildings are permanent and complete with a consultation room and a room where women who have just given birth can stay overnight. In fact, some midwives live at the polindes. Several polindes buildings have been built under community initiative other than through KDP activities. However, some polindes are still in temporary structures and do not have water or electricity. Based on observation, many posyandu in the sample areas do not have a permanent building. This is in accordance with the initial concept of posyandu that they belong to the community, so most of them are not housed in a permanent structure. Nevertheless, many community members wished for the posyandu to be housed in a permanent structure. Therefore, in several villages, permanent posyandu facilities are built by the community and in others, they are built through the KDP activities. Donor institutions also help to build health facilities, as is the case with Plan International which has erected midwife housing, polindes, and lopo for posyandu activities in several villages in NTT. 3.1.3 Other Obstacles Faced and the Need for MCH Service Providers A lack of transportation is the main obstacle that village midwives, who must provide health service coverage over wide areas and in isolated areas, face. The situation is even worse where there are no basic facilities such as electricity. Midwives require a motor vehicle or another vehicle that can reach isolated areas on damaged and steep roads. The small number of village midwives compared to the size of the area they must cover results in a heavy workload for midwives. Workloads become even greater in areas with poor roads. Ideally, villages that cover a wide area and are isolated require more than one village midwife. Under existing conditions, there are village midwives that combine two posyandu or more in one posyandu session. Thus, the community in the distant and isolated areas must endure a long journey to attend the posyandu. As a result of the heavy workload due to the obstacle of physical access, village midwives in NTT are more reliant on income from delivery fee reimbursements from Askeskin (Asuransi Kesehatan Keluarga Miskin--Health Insurance for the Poor) or payments ranging between Rp50,000 and Rp100,000 per delivery from the community. The process of Askeskin fee reimbursal occasionally does not progress smoothly. For example, if the administrative details are incorrect (e.g., if the delivery date is incorrect), the insurance claim will not be reimbursed. Delivery fees in NTT are less than they are in West Java, where they range between Rp400,000 and Rp600,000. Because of the presence of private midwife practices, as is the case in West Java, it is difficult to differentiate between official working hours and private practice opening hours. This also makes it difficult for the community to differentiate between government and private fees, as the village midwife will often service a private patient in their house during official working hours. Unlike in West Java, in NTT village midwives do not conduct private practice.16 16 Village midwives in NTT do not open practices, but several midwives admitted that if they provide services outside the polindes working hours, they can receive a higher service charge (e.g., Rp10,000). The SMERU Research Institute 19 3.1.4 Cooperation with the Community and the Reach of Specific Groups The government still dominates efforts to proactively provide MCH services. With the exception of posyandu cadres, in general the entire community still become service users. They are not directly involved in decision-making processes related to service provision. Any increase in MCH services also are still highly dependant on the government and other service providers. Nevertheless, the level of community participation in assisting with the construction of health facilities is very high, as seen in NTT, where polindes and midwife housing are generally built by villagers. Cooperation between MCH service providers and the community, including village officials and community figures, is generally very good. In fact, the community is highly supportive of and reliant on posyandu. In several areas, the community voluntarily decided to charge a fee of between Rp500 and Rp1,000 per service for the provision of supplementary food such as green bean porridge or other nutritious food. Community members are also willing to become posyandu cadres, even where there is no incentive or the incentive is negligible. In many areas, community members are prepared to walk for several kilometers to attend the posyandu services. Support from village officials and community figures towards modern MCH services is also great. Apart from providing information about the importance of MCH, they also visit the houses of community members who do not attend the posyandu activities. Village officials are also often present during posyandu activities. In several areas, village officials have also agreed to apply fines supported by village regulations. In Oehela village, TTS, for instance, a fine of Rp2,500 is applied for pregnant women or mothers of under-fives who do not attend the posyandu. In NTT, donor institutions have a fairly dominant role in urging the community to use MCH services. CARE has constructed nutrition rehabilitation posts in several villages, while Christian World Service (CWS) has provided supplementary food aid such as milk for pregnant women as well as vegetables, eggs, et cetera, apart from offering lessons on healthy cooking methods. CWS also provides de-worming treatment for children. In addition, World Food Programme (WFP) provides milk, sugar, cooking oil, and biscuits. In general, MCH service providers do not experience problems reaching specific community groups, including groups that to date use dukun beranak. However, they can experience difficulties when trying to reach at least three specific groups: (1) farmers who work in fields that are far from the settlements, (2) fishermen who sail to other regions, and (3) community groups that still follow the custom of se'i (see Box 1). In Taunbaen village, TTU, at the end of the dry season, the community usually clears the land, which is usually located far from where they live, before planting it with food crops or commercial crops within a time frame of two months. Women in the later stages of pregnancy are still involved in these activities, so the village midwives cannot reach them as they are too far from the main settlement. This is also the case in Oehela village, TTU. Because there is no farming land in the village, the community generally buys or leases land outside the village which can be up to ten kilometers away from their houses. They build temporary houses on the land which they occupy during the land preparation and harvest seasons, making it difficult for village midwives to reach them. 20 The SMERU Research Institute In Cirebon District, fishermen are often forced to look for fish outside their region. This is described by a coordinating midwife in Mundu, Cirebon, West Java, "When fishermen have to look for fish outside the region, they usually take their whole family. Thus, it is difficult for the health workers to ensure they are routinely checked." In TTU and TTS districts, there are still groups who believe and practice the custom of se'i, as discussed by the head (male) of a puskesmas in TTS, NTT: "After giving birth, there are still many mothers and infants who have to undergo se'i for 40 days that make them unable to access MCH services. Thus, the health workers are the ones who have to visit them." Box 1. Se'i The practice of se'i, which literally means 'roasting', is done after the delivery process. In TTS, the new mother must stay in a round house (roof and walls made from a kind of long grass), while in TTU, the mother stays in one room in a house. A hot furnace is placed under the bed. The husband usually starts to prepare firewood when his wife is in her seventh month of pregnancy. The community state that the mother and infant must stay in the condition of se'i for a period of 40 days. The woman is not permitted to leave the se'i room, except when it is absolutely necessary. If she wishes to go out of the room, the mother's entire body must be wrapped in cloth or a blanket. During se'i, the mother must only consume hot food and drink. Bose corn (corn that is mashed) is considered to be the main food of women who have just given birth so that she recovers quickly and produces plenty of breastmilk. In Sekon village, Insana, TTU, women must eat hot porridge and drink hot water. The se'i process distrupts MCH service process as the infant cannot be immunized until after the 40 days are over and the mother cannot start postnatal care. The village midwives lament this fact. However, the tradition is still difficult to break in several villages. In fact, in Hauteas village, North Biboki, TTU, several mothers insisted to follow the se'i tradition, even though it was forbidden by the village midwife, and they chose not to use the midwife during pregnancy and delivery, and after delivery. The Health Office, midwife, and posyandu cadres have all explained that se'i is dangerous, as infants and mothers can contract pneumonia and experience dehydration, undernutrition, sinus infections, and anaemia. However, in several cases, the community does not fully understand the risks. According to a discussion among FGD participants in Sekon village, sometimes because the mother must follow se'i, a midwife's actions may be contradictory to se'i; for example, perineal sutures can lengthen the recovery process during se'i. 3.1.5 Traditional Services Although the number and function of dukun beranak17 are on the decline, they still exist, as outlined in Table 4. The table also indicates that in NTT, the number of dukun beranak is actually increasing. This is seen in some areas such as Insana and Kie subdistricts for trained dukun beranak and North Biboki for untrained dukun beranak. It is also astonishing that the number of untrained dukun beranak is actually increasing in urban areas (Alak and Maulaffa subdistricts). 17 Dukun beranak are referred to as dukun bayi in the Village Potential (Podes) data. The SMERU Research Institute 21 Table 4. Number of Dukun Bayi/Beranak, Trained and Untrained Number of Trained Number of Untrained Puskesmas Subdistrict Dukun Bayi Dukun Bayi West Java Sumedang (Podes data) 2003 2005 2003 2005 Rancakalong Rancakalong 34 29 0 0 Buahdua Buahdua 23 23 1 0 Darmaraja Darmaraja 33 30 2 0 Cirebon (Podes data) 2003 2005 2003 2005 Susukan Susukan 35 32 6 2 Mundu Mundu 26 17 0 10 North Cirebon North Cirebon 11 10 0 2 NTT TTU (Podes data) 2003 2005 2003 2005 Lurasik North Biboki 31 30 23 24 Oelolok Insana 35 51 42 25 Nunpene East Miomaffo 90 78 59 33 TTS (Podes data) 2003 2005 2003 2005 Kie Kie 38 45 63 46 Batu Putih Batu Putih 28 25 2 29 Kupang (Podes data) 2003 2005 2003 2005 Bakunase Maulaffa 24 7 1 4 Alak Alak 44 29 15 39 Source: Podes 2003 and 2005 (processed from data for each village) In the majority of areas in West Java, with the exception of the isolated areas, the presence of dukun beranak and their role are steadily declining. In fact, their presence is shifting from being involved from the initial stages of the delivery process to only acting as an assistant for the midwife, having a greater role in caring for the mother and infant, or acting as a supplement to the service provided by the midwife. Several statements from informants are provided below. The paraji18 is only there as an assistant. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) There are still some [paraji] that use massage. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) An increasing number of the community use a midwife. Apart from the fact that there are no new paraji, it is also because midwives are safer, offer treatment with medicines, and more comprehensive equipment, such as a blood pressure monitor. They visit you until the umbilical cord stump has fallen off as well as provide birth certificates. (Village head in Darmaraja, Sumedang, West Java) The paraji are usually only for customary ceremonies, such as digeyong [swaying the baby to and fro] and things like that. There are also ceremonies for placenta burial that are also done by the paraji. (Men's FGD, Mundu Pesisir, Mundu, Cirebon, West Java) The presence of a government regulation that the delivery process is only to be performed by a midwife has had a role in the reduction of the role of dukun beranak. In Sumedang District, dukun beranak that assist with the delivery process must pay a fine, while in Susukan Subdistrict, the midwive will actually give money up to Rp25,000­ 18 In West Java, dukun beranak are also known as paraji. 22 The SMERU Research Institute 50,000 if the dukun beranak wants to work with the midwife to assist with the delivery. One dukun beranak in Darmaraja, Sumedang, West Java offered the following account: "In the past, each month there were three deliveries on average, but now after the regulation that we must give assistance with the midwife, it is rare." From time to time, the amount of training that puskesmas provide for existing dukun beranak is cut back and nowadays, no training is provided for new dukun beranak. In NTT, dukun beranak--both women and men--are still involved during pregnancy, mainly for checkups and correcting the foetus's position, and in the delivery process. In Table 4, it is evident that the numbers of dukun beranak in several subdistricts have actually increased. This increase is due to the shortfall in the number of village midwives and the difficulties faced by village midwives in accessing residents living in isolated areas.19 Communication and cooperation between traditional (health) service providers and (modern) MCH service providers in the majority of sample areas are good. The Sumedang District Government's "Tri Mitra", or "Three Partners", policy20 has strengthened communication and cooperation between village midwives, dukun beranak, and posyandu cadres (see section 3.2.4). The policy has also reduced competition between traditional health service providers and modern MCH service providers. In Cirebon District, dukun beranak are now involved in quarterly coordination meetings held at the puskesmas. Both village midwives and dukun beranak in Cirebon acknowledge that there is no competition between them. In NTT, dukun beranak have actually become posyandu cadres. 3.2 Demand and the Factors Influencing Demand for Maternal and Child Health Services 3.2.1 Community Knowledge and Awareness of the Importance of Modern MCH Services In general, the majority of the community in the sample villages/kelurahan have good knowledge, understanding, and awareness of the importance of modern MCH services. Only in areas which are isolated and/or where a large number of the population is poor are there some community members who do not use modern MCH services. However, there are no communities who have never used modern MCH services. Among all of the modern MCH services available, the community would have at least accessed one or several of the services, as explained by a village midwife in Darmaraja, Sumedang: For pregnant women, it can be said that all of them have done health checkups routinely. During delivery, there indeed are still those who use paraji services; however, it is always asked that they always inform the midwife. While for postnatal, although there are still those who are helped by the paraji, they actually still have themselves checked by the midwife. 19 Three villages in Kie Subdistrict do not have a village midwife: Falas, Fatuulan, and Tesiafano. 20 The "Tri Mitra" policy regulates that all the village midwife, dukun beranak, and posyandu cadre have to attend to deliveries together. The SMERU Research Institute 23 During pregnancy and delivery, the majority of the community choose to be observed by the village midwife, and after birth, they again have themselves and their infants checked by the village midwife (see Appendices 13­15). In discussions with groups of women and groups of men that are parents to under-fives, the village midwife often emerges as the first suggestion as the service provider used during pregnancy, delivery, and postpartum, followed by dukun beranak.21 In the majority of sample districts in West Java and NTT, there are no differences to the order of responses between isolated rural areas or rural areas with easy access, or even urban areas. This is reflected by the following statements from several FGD participants. If Midwife Eulis is not available, then we go to the puskesmas; but, Midwife Eulis is the main one. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) We always go to Midwife Tilde [a village midwife in Kuanek, TTU] because she is always ready, not only at the polindes during opening hours, but also at night if she is telephoned. Even when it is raining, we will go to the midwife because from her, we can get all the health services for mothers and babies here. It is the midwife who gives the injections, immunizations, and medicines, and teaches us how to look after a baby and how to breastfeed a baby. The midwife has done many good things. (Women's FGD, Kuanek, East Miomaffo, TTU, NTT) Nevertheless, in Nagarawangi village, Sumedang; Jagapura Kidul village, Cirebon; Falas village, TTS; and Kelurahan Fatufetto, Kupang, dukun beranak or paraji emerge as the first service provider during delivery. Dukun beranak also emerge as the first choice for providing postpartum services in the following villages: Neglasari and Buahdua in Sumedang, Jagapura Kidul and Mundu Pesisir in Cirebon, Falas in TTS, and Naikolan in Kupang. After delivery, the community in NTT do not generally use dukun beranak, unlike in West Java. A man from Mundu Pesisir village, Mundu, Cirebon, West Java confirms: "Yes. It is like this, Sir. If you go to Ibu Dede, you are also helped by Ibu Ayu. But, it is like this at the house, Midwife Dede and Bu Ayu only monitor. So, after that you get helped by Mbo' Kunah until puput (placenta comes out), until digeyong, and the customary ceremony." (Men's FGD) Community choice of location to receive village midwife services can differentiate West Java and NTT. In West Java, during pregnancy, the community tends to have their health checks done at the home or private practice of the village midwife, at the posyandu, or in the puskesmas. During delivery, they go to the midwife practice or call the midwife to their house. In NTT, the community is heavily reliant on posyandu and polindes for routine pregnancy checks. During delivery, they also rely on the polindes or call the village midwife to their house. Community dependency on polindes in NTT is so high because they are always open and ready to service the community each day, while in West Java, they are only open once or twice each week. The community bases their choice of the village midwife on their knowledge that the midwife's services will be medically sound. So, the community is more likely to choose the village midwife because they can attend risky deliveries, they possess comprehensive equipment and medicines, they can provide "suntik sehat", and can write referrals to the 21 Data is processed from four FGDs in each village: two FGDs with women and two FGDs with men, and then collaged according to rural and urban areas, as well as access (rural with easy access, rural with difficult access, and urban). 24 The SMERU Research Institute hospital, besides their being concerned about their first child being handled by the dukun beranak. Other reasons for choosing the village midwife are that delivery fees can be paid in installments even though they are relatively expensive when compared with the delivery fees for a dukun beranak; they are scared of being fined; they are scared that if they do not deliver with the village midwife, the midwife will not provide any more health checks; and they can obtain other facilities like birth certificates, baby items, and ear piercing for girls. The following several statements provide an overview: In the case of hypertension or a risky pregnancy, the midwife can handle it. She handles it faster. The midwife also gives "suntik sehat" after the mother gives birth. (Women's FGD, Susukan, Susukan, Cirebon, West Java) The midwife has comprehensive equipment. She has infusion equipment, blood pressure monitor, injections, medicines, scales for infants. The midwife also provides a room in the polindes for mothers who have just given birth. (Women's FGD, Kuanek, East Miomaffo, TTU, NTT) The delivery fees with the midwife are actually more expensive, but luckily, they can be paid in installments. You can just defer payment if you don't have any money. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) You can deliver with Rp350,000 with the midwife, including the birth certificate. (Women's FGD, Neglasari, Darmaraja, Sumedang, West Java) If you don't use the midwife, then later the midwife will be angry. (Men's FGD, Hauteas, North Biboki, TTU, NTT) I'm scared to not give birth with the midwife; later, if anything happens, for instance if the child is sick, the midwife will not want to check it. (Women's FGD, Oehela, Batu Putih, TTS, NTT) The majority of the community have had their children immunized with the help of the village midwife. Immunizations are mostly done at the posyandu (see Appendix 16). High community awareness of the need to immunize their child is evident as generally, when mothers cannot take their child to the posyandu or when they miss the scheduled session for their child's immunization, they will take the child to the nearest polindes or puskesmas. In fact, in West Java, they go to the midwife practice for their immunizations. Several fathers also had knowledge about immunizations, even knowing the number and type of immunizations that their child is given. Below are observations by several community members : All children are immunized at the posyandu. There is BCG, hepatitis, polio, and measles. (Women's FGD, Taunbaen, North Biboki, TTU, NTT) Basically, children must be fully immunized until they are complete. If the immunization schedule is fixed, everyone attends except for children that are sick. (Men's FGD, Gegesik Kulon, Gegesik, Cirebon, West Java) Nevertheless, there are still a minority of under-fives who were not initially immunized because their parents were concerned that their children would run a temperature after being immunized and it would trouble the parents. In cases like this, the village midwife The SMERU Research Institute 25 or posyandu cadre will make an effort for the child to be immunized by picking up the child and parent from their house and taking them to the posyandu. In several areas, the hamlet head involved himself by picking up the mothers so that they could attend the posyandu to immunize their child. Concern over possible side effects from immunization is reflected in the following statements. There are certainly children who are not immunized due to fears that they will run a high temperature after being immunized. Moreover, after watching TV that there are some who have died and become paralyzed after being immunized, there are some community members who are scared. (Women's FGD, Jagapura Kidul, Gegesik, Cirebon, West Java) [Parents are] scared that their child will get a temperature; then, later that night, they will be fussy and cry after the injection. (Men's FGD, Tangkil, Susukan, Cirebon, West Java) Community knowledge and awareness of the importance of weighing infants and children are good and the majority of the community use the posyandu for this service (see Appendix 17). Financially well-off urban residents, such as some of the residents in Kupang City, take their childrentoanobstetriciantobeweighedandimmunized. All children are weighed at the posyandu or polindes. We want to know if a child is malnourished or not. (Women's FGD, Kuanek, East Miomaffo, TTU, NTT) Children are weighed at the posyandu and their weight is recorded in a book by the cadre. (Men's FGD, Bojongloa, Buahdua, Sumedang, West Java) Community awareness about malnutrition prevention and nutritional treatment is good. The majority of the community obtained their knowledge about nutrition from the posyandu and the village midwife. In the majority of posyandu, the community in fact voluntarily pay a fee for supplementary food to be provided. The community also knows that when an under-five is undernourished, the child will be treated at a designated puskesmas or will be directly referred to the district hospital (see Appendix 18). Usually a cadre or the midwife will send children who have reached the red line or are underweight to the puskesmas. The child gets milk for several months so that their weight will increase. Bapak Kuwu [the village head] also occasionally gives food in the village office; the women cook it. (Women's FGD, Susukan, Susukan, Cirebon, West Java) If there is a malnourished child here, then the midwife will provide vitamins. The cadres also give food. Or, the parents are told to take the child to the puskesmas or to Soe where there is a place that receives malnourished children. (Men's FGD, Oenay, Kie, TTS, NTT) Although community knowledge about nutrition in NTT is fairly good, financial limitations cause them to be unable to provide sufficient nutritious food to their children. It is evident that there are still quite large numbers of undernourished, malnourished, and severely malnourished children in each village, between 10 and 40 cases, clearly indicating that there are problems in fulfilling nutritional requirements. In addition, the large amount of assistance in the form of formula, rice, and eggs for undernourished children means that some mothers are inclined to let their child become undernourished and that 26 The SMERU Research Institute they are "pleased" if their child is categorized as undernourished, as has occurred in Oenenu village and parts of North Biboki, TTU: I see that the number of undernourished children in this subdistrict tends to increase. In my opinion, the obstacles surround the low awareness of mothers to pay attention to their children's food and it is evident that there is a tendency that where there is a lot of assistance for undernourished childrenmothers are inclined to let their child become undernourished in order to receive assistance. (Puskesmas head (female), TTU, NTT) The additional nutritious food for children [at the posyandu] is not free. Our economy is weak so we have to pay. It's difficult. (Men's FGD, Oehela, Batu Putih, TTS, NTT) We are not satisfied because only malnourished children receive assistance. My child won the healthy child competition, so we don't get anything. Let alone, the mothers that often get assistance are jealous of those who don't get assistance. (Women's FGD, Oenenu, East Miomaffo, TTU, NTT) Posyandu are the spearheads of modern MCH services for the community; however, it is clear that in the majority of sample areas, community interest in posyandu is lacking. This is indicated by the community posyandu attendance levels that are still below target. Based on observation at several posyandu, community attendance levels range from 29%­95%. In urban areas, attendance levels are even lower (Table 5). In NTT, as posyandu are the mainstay for MCH services, attendance levels are higher. A posyandu cadre comments on posyandu attendance: "Basically, everyone has been to the posyandu, but attendance at each activity only ranges around 50% of the total listed under-fives" (Posyandu cadre, Jagapura Kidul, Gegesik, Cirebon, West Java). There are several reasons why the community does not use posyandu services, including that (1) the child is scared to go on the scales, (2) there is a belief that the scales are wrong, (3) the child is sick, (4) they do not want to because their children's immunizations are complete (for children above three years), (5) no supplementary food is being provided, (6) the location is not interesting or there is no children's play area (Bojongloa, Sumedang), (7) they are usually picked up by the posyandu cadre or a village official, (5) they are busy working or otherwise busy (e.g., trading at the market, at sea, or harvesting), (6) there is no one to take the child (e.g., the mother is a migrant worker and the grandmother is considered to be too old and unable to go to the posyandu), (7) there is a false perception that there is no relationship between weighing under-fives and health, (8) they are embarrassed to go the posyandu because of having too many (more than five) children and giving birth over the age of 4522 (Mundu Pesisir, Cirebon), and (9) road conditions are poor or the river cannot be crossed during the rainy season. The following several statements reflect the above findings. When the posyandu is scheduled, the women are selling cloth at Tegal Gubung. They are more concerned about looking for money. Others are lazy. They have been invited, but they don't want to attend, although it has already been announced by the RW head through the mobile loudspeaker. (Women's FGD, Susukan, Susukan, Cirebon, West Java) 22 In Mertasinga village, Gunung Jati Subdistrict, a 45-year-old FGD participant was pregnant with her eighth child. The SMERU Research Institute 27 I don't want to go to the posyandu. My child's weight is not increasing ... Maybe the scales are wrong. What's more is that if there is no supplementary food, only half of the patients attend. It's different if there is food; it's full, with a queue. (Women's FGD, Bojongloa, Buahdua, Sumedang, West Java) The parents consider their children to be healthy, so they don't need to be weighed. It [the weight] is irrelevant. (Men's FGD, Jagapura Kidul, Gegesik, Cirebon, West Java) Usually if mothers don't take their children to the posyandu, it is because they have to walk a long way or because of the rainy season and floods, which definitely make it harder. If they are harvesting or busy planting or clearing the grass, then they also won't come to the posyandu. (Men's FGD, Falas, Kie, TTS, NTT) Table 5. Posyandu Attendance Levels during Field Observation Number of Under- Number of fives that Attendance Posyandu/District Village Registered Attended during % Under-fives the Observation Sumedang Arwana IV Nagarawangi 47 38 80.85 Merpati 2 Pamekaran 16 9 56.25 Tampomas 1 Buahdua 72 65 90.28 (Not observed) Bojongloa - - - Tulip 2 Neglasari 108 59 54.63 Flamboyan 1 Sukaratu 100 49 49.00 Cirebon Gandarasa V Gegesik Kulon* - - - Merpati III Jagapura Kidul 107 40 37.38 Sumber Jaya Susukan 58 45 77.59 (Not observed) Tangkil - - - (Not observed) Mundu Pesisir - - - Lawang Mas Mertasinga 56 47 83.93 TTU (Not observed) Taunbaen - - - Pos 1 Hauteas 75 44 58.67 Posyandu A and B Sekon 143 126 88.11 (Not observed) Susulaku - - - Tekin 1 Oenenu 99 90 90.90 Posyandu B Kuanek 60 57 95.00 TTS Posyandu A Falas 57 53 92.98 Pos II Feuknoni Oenay 140 128 91.43 Boentuka Boentuka 19** 19** 100 (Not observed) Oehela - - - Kupang Sehati Naikolan 110 41 29.29 Melati 2 Fatufetto 125 45 36.00 Source: Results of posyandu observation during field research Note: Several posyandu could not be observed as no activities were scheduled during the field research. *The data on attendance of under-fives in this posyandu could not be verified; hence, it is not included in the table. ** Pregnant women only Although community knowledge and awareness of modern MCH services are good and the majority of the community have used modern MCH services, some community members still only use a dukun beranak. In addition, some women only give birth with the assistance from their husband, parents, or other family members, while others want to be assisted by the dukun beranak when delivering with the village midwife. One man from Sukaratu village, Darmaraja, Sumedang, West Java states, "Some [women] still deliver with the paraji, but they are always assisted by the midwife." (Men's FGD) 28 The SMERU Research Institute It is explained above that the community already has an adequate understanding of various modern MCH services, such as safe delivery, immunization, weighing infants, nutritious food, breastfeeding, and family planning. It is not surprising that the community obtains most of their information about various health services from the village midwife and posyandu cadres as they can be accessed almost every day. The community also receives information from the puskesmas, doctors, and, specifically for family planning, the family planning officer. A significant number of community members also obtain information from the television, newspapers, books, posters, or pamphlets. Village officials, PKK women, family, neighbors, or friends also contribute to the spread of information about various MCH services although this is not as effective in disseminating information as the other channels mentioned above. From the many sources of information listed above, midwives are placed as the primary source of information that the community can trust. Posyandu cadres hold the second position, followed by doctors. The amount of trust that the community has in the midwife is clearly understandable as the midwife faithfully takes care of and pays attention to their health from time to time, as well as because midwives are formal health officials. The community obtains information from the above actors when they see them for medical needs or during various formal and informal meetings. However, the community has not obtained information from a socialization program deliberately planned to disseminate information about modern MCH services. 3.2.2 Obstacles to Physical and Financial Accesses Isolation (difficult physical access) is the main obstacle for the community in accessing modern MCH services and thus they do not use modern MCH services. Isolation is caused by several factors: (1) a great distance to the modern MCH service location, poor road conditions, steep roads, no bridges for river crossings, and forest passes; (2) a lack of transportation or high transportation costs (Rp8,000­Rp40,000 per trip); (3) no electricity making the road dark and vulnerable to robbery; (4) lack of a village midwife; and (5) the community's only reliance on posyandu or pusling, or puskesmas officers who are in fact not always present. These conditions are conveyed in the following statements. The midwife is too far away [about 4 kilometers], and there are thieves in the evening. This makes us scared to go there at night. The road to get there is also really bad. You feel like you want to die if you have to go there. Apart from that, the community has to cross a river that does not have a bridge, and so during the rainy season, they automatically cannot cross [the river] and reach the health facilities. (Men's FGD, Hauteas, North Biboki, TTU, NTT) The road to the puskesmas or health facilities has to be good. We have a really poor road. You want to die. It is hard to go to the midwife at night. It is a long way. So, we just use the dukun [beranak]. (Men's FGD, Hauteas, North Biboki, TTU, NTT) ... With the average economic condition of the community being low, combined with long distances and poor road conditions, particularly in the rainy season where the road is usually muddy and they have to cross a river with no bridge, in moments like this, occasionally, they have to take the attitude to not use the available health facilities. (Puskesmas head (female), TTU, NTT) The SMERU Research Institute 29 A great distance means that women about to give birth are unable to wait for the midwife to arrive; it's even worse if the midwife is not available when needed. This means that the majority of women are more inclined to choose the dukun beranak. Apart from physical obstacles, financial obstacles, such as the expense of delivery fees, and the need to work far from the settlement are also major obstacles to the use of modern MCH services. In several sample villages, this is mainly caused by the high delivery fees set by the village midwife when compared to the cost of a dukun beranak. Village midwife delivery fees are Rp400,000­600,000 in West Java and Rp50,000­ 100,000 in NTT, while dukun beranak charge a maximum fee of Rp100,000 in West Java and Rp50,000 in NTT for their services. If they are helped by a midwife, they do not know what and how much to give. If the amount is quite big, they cannot afford it. That's the problem. So, it is just better to go to a dukun [beranak], so that the fee is negotiable. (Village midwife, Oehela, Batu Putih, TTS, NTT) Reasons for using a dukun beranak's services? Well, because of the problem of fees. If you use a dukun beranak, it is cheaper. Maybe it's also because of the trust factor. (Men's FGD, Jagapura Kidul, Gegesik, Cirebon, West Java) In the Darmaraja Subdistrict region, there are still mothers who use the dukun beranak service for the reason that the fees are relatively cheap, at only half of the midwife's service fees, and the dukun's services are usually given in a longer time. (Puskesmas head (male), Sumedang, West Java) Those who don't deliver with the midwife don't have the fees and it is far from their house. (Men's FGD, Mundu Pesisir, Mundu, Cirebon, West Java) These fees are indeed high when compared to the incomes of farm laborers or other heavy laborers, or fishermen. To demonstrate, a fisherman's income in Cirebon is based on the season and during several months of the year, they often do not go to sea due to the west seasonal wind, while farm laborers may only receive Rp20,000 per day. While delivery fees in NTT are relatively cheap compared to the national measures, the local communities feel that the fees are terribly expensive, considering their low economic ability and infertile land conditions in a large number of villages as described by one village head in Batu Putih, TTS, NTT: "If you are born in Oehela, it is as if you have gone straight to hell." The introduction of Askeskin did not immediately make the community turn to modern MCH services because it does not actually cover all poor families and is only valid for the birth of the first child, while many poor community groups have more than one child. In fact, in several areas, some have many children (in the coastal areas in Cirebon District). The following statement depicts these conditions. Usually those who cannot afford to go to the midwife or puskesmas are the poorest, but they don't have an Askeskin card. There are a fair number of them because only 141 [of the total of 391] household heads have Askeskin cards. Sure they can get free service as long as they have arranged for an SKTM23 to be made, but it seems that not many of them want to arrange it. (Village midwife in Hauteas, North Biboki, TTU, NTT) 23 SKTM stands for surat keterangan tidak mampu--certificate of financial incapability; an official note informing that someone is financially incapable. 30 The SMERU Research Institute In some parts of Sumedang District, apart from the positive aim of the "Tri Mitra" policy, according to the community, the fees for deliveries handled by the midwife together with a dukun beranak and a posyandu cadre have become more expensive. In the past, if they only used midwife services, they only paid the midwife, but now they must also expend additional fees of approximately Rp100,000 for the dukun beranak and for the posyandu cadre (usually taken from the midwive'sfee). Farming activities that are far from home make it difficult for community members to access modern MCH services, particularly in TTU and TTS. In an area such as Taunbaen village, TTU, at the end of the dry season, the locals usually clear land which is far from their homes, before planting it with food crops or commercial crops. They do this over a period of two months. Women in the late stages of pregnancy are still involved in these activities. When they give birth, they are unable to return to their home or to be taken to the village midwife or polindes, so women frequently deliver in the field only assisted by their husband or a dukun beranak that can be called immediately. In Oehela village, Batu Putih, TTU, because there is no farming land in the village, the community generally buys or rents land located up to 10 kilometers away from their house in the village. They build temporary houses on the land which they occupy during the land preparation and harvest seasons. If they need health services, for example if a woman is in labor or if a child has a fever, they have no other choice but to call a dukun beranak or only rely on their husband to help them deliver. A woman from Oehela village, Batu Putih, TTS, NTT shared her account: "I used the dukun [beranak] because when I gave birth, I was in the house in the field and it was raining. My husband called the dukun [beranak] to help me." (Women's FGD) 3.2.3 Quality of Modern MCH Services It is of course the case that community choices for MCH facilities are also influenced by the performance of the service, which can be measured by the level of community satisfaction. For the community, a measure of satisfaction and good service quality is friendly attitude towards patients, low fees and the option of installments for the less-well-off, good and clean facilities (location), a queue that is not too long, effective medicine, the ability to provide 24- hour service if needed, and comprehensive facilities. Based on these criteria, Table 6 presents community satisfaction levels towards modern MCH services. Communities are generally satisfied with the services provided by the village midwife and polindes. The reasons that they give include that the village midwives can help the delivery process, the patient does not feel pain after given an injection, there is comprehensive equipment (infusions, blood pressure monitor, suction pump for amniotic fluid), the village midwives can refer patients to the puskesmas or hospital if there is a problem, they can treat sick children, they are able to give good quality medicine, they give sincere and honest services, they are patient and willing to wait until morning, and they are thorough and caring. Communities also like it that they can pay the fees in installments. These feelings are reflected in the following statements. Midwife Yuliana is happy to come at whatever time if she is called. She services us 24 hours a day, and she will even come to our hamlet which is so far. (Women's FGD, Oenay, Kie, TTS, NTT) [Midwife Dede] is patient [and] persevering, [and] has adequate facilities. Her fees can be paid in installments before or after delivery, and [we] can consult. (Women's FGD, Mundu Pesisir, Mundu, Cirebon, West Java) The SMERU Research Institute 31 Table 6. Satisfaction Levels for Modern MCH Services Service Level of Reasons Provider Satisfaction Village Generally The delivery process does not cause pain after given an injection. There is midwife satisfied comprehensive equipment (infusions, blood pressure monitor, suction pump for amniotic fluid). They can refer patients to the puskesmas or hospital if there is a problem. They can treat sick children. They give good quality medicine. They are sincere and honest in their service, patient waiting until morning, and thorough. Correct medicine is provided. They come at the right time and there is no need to be fetched. They are good, patient, friendly, and adept. They come to the house. The fee includes birth certificate (in many places, a bag is given and it also includes ear piercing). The services can be paid in installments. They allow the husband to be present when the wife delivers. They often ask about the patient and the patient gets an explanation. They are pretty. A minority They are not available when the patients need them. They are not thorough. JPS dissatisfied (jaring pengaman sosial--social safety net) health card holders are often not given first priority. Fees must be fully paid (installments system is not available). The medicine is ineffective. They are rude and impatient, and do not accompany patients if the patient is in labor pain, are rude when assisting with delivery. Posyandu Generally They come from the community, so they give attention to the community. They visit cadre satisfied or fetch those who do not attend. They immediately provide assistance, announce the activities, service MCH before going to the midwife, and are friendly. Posyandu Generally It is held each month and is always attended by a midwife. Under-fives are satisfied weighed and immunized. Immunizations are as scheduled and correct dosage is given. Supplementary food is provided. There is a sufficient number of cadres. The scales are good. A minority No supplementary food is provided (in certain posyandu, you are even given chiki dissatisfied [a kind of kid snack]). No vitamins are given. Officers from the puskesmas are often late. Immunization dosage is incorrect. Puskesmas Some Treatment is only given as much as is necessary and is not thorough because dissatisfied there are too many patients. Askeskin/Gakin (that is, JPK Gakin­Jaminan Pemeliharaan Kesehatan Keluarga Miskin--a government sponsored health care insurance for the poor) patients are not given proper attention. The queues are long. The midwives change. Sometimes the wrong medicine is given. The midwives are unfriendly. Some It is free/cheap. There is a doctor and many midwives, some of whom are friendly. satisfied It is clean and gives good service. Patients queue according to number. Patients recover quickly. If you ask for good medicine, you are given good medicine. The medicine is effective. There is a proper queueing system. The checkup is thorough. The nurses are kind. There are full medical staff: pediatricians and dentists. There are facilities for blood tests. Secondary Generally Medicine is ineffective. puskesmas dissatisfied A minority There is comprehensive equipment. satisfied Public Generally Askeskin/Gakin patients are not given proper attention. Patients must present Hospital dissatisfied money up-front (if you have money, you can get treatment; public hospitals now tend to have no feeling). Nurses and administration staff are unfriendly/harsh. Medicine is expensive. A minority Equipment is sophisticated. There are doctors and they are good, too. Medicine is satisfied comprehensive. Medicine is not different regardless of whether you are an Askeskin/Gakin patient or a general patient. The facilities are good. There are vitamins for anaemia. Patients can get prenatal checks, including with ultrasound. The doctors are handsome. Doctor's Generally The fees are expensive, but patients are satisfied with the outcomes: The medicine practice satisfied is good; The checkups are thorough and in accordance with the schedule. Vitamins are given. Ultrasound is available. Source: FGD results 32 The SMERU Research Institute Dissatisfaction to village midwife services is often related to the character of the midwife in question, the ineffectiveness of the medicine they provide, the midwife's lack of experience, difficulties reaching the midwife, and the midwife's not being always available. The community is not satisfied if the midwife is impatient or unfriendly. When a woman is in labor, she usually requires patience and friendliness. In addition, some midwives who are generally younger than the dukun beranak are also considered to be lacking the experience. Almost all communities are satisfied with the services provided by posyandu cadres. Apart from being satisfied with their weighing of infants and cooking for children at the posyandu, the community also consider posyandu cadres to be capable of giving information and care, actively informing the residents, or collecting them to take them to posyandu activities. In Sekon village, Insana, NTT, the community is often dissappointed with the services of puskesmas officers who do not attend posyandu services as this means that immunizations must be postponed until the posyandu session scheduled for the next month. The community is also dissapointed when the puskesmas officers often come late to the posyandu.24 Some sections of the community are dissatisfied with the MCH service facilities outside the village, particularly puskesmas and referral hospitals. This is related to the character of service providers (not thorough, unfriendly), the long queues, the feeling that Askeskin beneficiaries are often demeaned, the medicine that is ineffective, and the same medicine being provided for different illnesses. Several examples are listed below. I'm less than satisfied because they are not thorough, unfriendly, and sometimes rude. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) In the past, we paid at the puskesmas. Now, it is free, but sometimes they make safety net beneficiaries sometimes feel demeaned. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) I'm quite dissappointed as in the past when I was hemorrhaging, I was admitted but I had to have cash first before I was attended to. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) Yes, we have to be patient. It's good, though. Only, because there are so many patients, you have to queue. The puskesmas is full. (Women's FGD, Sukaratu, Darmaraja, Sumedang, West Java) Unresponsive. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) Nevertheless, another section of the community is satisfied with puskesmas services because the patients are well cared for and given the appropriate medication for their illness and there are doctors that can give checkups. Some community members are satisfied with pustu services (Kelurahan Fatufetto, Kupang), which are mostly available and are accessed by urban communities, while others are dissatisfied (Kelurahan Naikolan). The main reasons for the dissatisfaction are that the medical equiment is 24On one occasion, the officer only arrived at 14:00, whereas the mothers and children had been waiting since 08:00. The SMERU Research Institute 33 uncomprehensive, there is a rude official, and often, there are no officers attending the pustu. The various sentiments are reflected in the below statements. We are not ignored. The service is fast. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) Satisfied, Sir, because the service is good. They have the full equipment. The doctor is kind. The medicine is the same regardless of whether you pay or if you are a Gakin [Health Care Insurance for the Poor] patient. The quality of the medicine is also the same. The facilities are good [and] comfortable. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) 3.2.4 Choosing Traditional MCH Services Apart from the reason of physical and financial access limitations, there are several no less important reasons why community members choose dukun beranak. 1. There is no midwife in the village. In several areas, the community is sometimes forced to use the dukun beranak because the midwife is often not in the village as they may not want to live in the village, they happen to be visiting their parents in the city, or look after their family who do not live in the village: When my third child was born, I was assisted by the dukun [beranak] because the midwife was not at the post at the time. (Women's FGD, Oehela, Batu Putih, TTS, NTT) The fees are cheaper. The baby is delivered before the midwife comes. [We] can pay in installments. [It's] because the paraji's house is close by. Midwife Dede is not available. (Women's FGD, Mundu Pesisir, Mundu, Cirebon, West Java) 2. Embarrassment. Community members may be embarrassed because they have many children, or husbands may not want another person to see their wife's genitals. 3. Trust and traditional beliefs. The community trusts and believes in the choice that their parents made to use the dukun beranak, to the point where it becomes the norm. 4. The midwife often does not have the same skills and experience as those of the dukun beranak. Dukun beranak are usually older and considered to have more live experience than the midwife. This means that patients feel that they can ask the dukun beranak about many things and that dukun beranak can provide guidance to new mothers about such things as breastfeeding, bathing their child, and other traditional health issues. The fact is that after the 1980s, there were many dukun beranak who were well-trained. Knowing this, the community's concern about the professionalism of the dukun beranak lessens and hence, they choose to use the dukun beranak. 5. "A mother's touch." The community considers that dukun beranak have a mother's touch and can position themselves as a "substitute" mother who is patient, able to calm down the mother, able to massage and rub, and able to service intensively and routinely: 34 The SMERU Research Institute ... You can get massaged. When you are about to deliver, you are accompanied. [They are] patient. (Women's FGD, Mundu Pesisir, Mundu, Cirebon, West Java) Dukun [beranak] helps the midwife to get water, small cloths, [and] massage your belly. (Men's FGD, Hauteas, North Biboki, TTU, NTT) 6. Customary ceremonies. Dukun beranak help with traditional ceremonies, such as ceremonies for fourth and seventh months of pregnancy, as well as the ceremony held on the fortieth day after the birth. They are also prepared to bury the placenta (in West Java). A woman from Jagapura Kidul, Gegesik, Cirebon, West Java explains that a "dukun beranak can also massage the mother for the first 40 days after the birth. The midwife only checks the mother and infant two or three times in the first week. After that, the dukun beranak has that role" (Women's FGD). 7. Blood relative. If a community member is related by blood to the dukun beranak, they are more likely to trust them and to not feel shy, and the fee will be very low: Now, everyone either goes to the puskesmas or the midwife. They only go to the paraji if it is really urgent, for example when kebrosotan [the midwife is not early enough that the baby is delivered without assistance] happens, they don't have money, they are afraid of the midwifery equipment, or they are related. (Dukun beranak, Sukaratu, Darmaraja, Sumedang, West Java) 8. If the foetus is positioned correctly and an uncomplicated birth is expected, the community just uses the dukun beranak. This is supported by the following statements. If it is expected that the infant's birth will not be difficult, yes, it's good enough to use the dukun beranak. (Women's FGD, Jagapura Kidul, Gegesik, Cirebon, West Java) My wife goes to the dukun [beranak] first. If the dukun is incapable, then we'll just go to the midwife; let alone, now a paraji also has to cooperate with a midwife. (Men's FGD, Mundu Pesisir, Mundu, Cirebon, West Java) 9. Dukun beranak can correct the position of a foetus in breach position with massage. Feelings of exhaustion and pain after delivery can go after being massaged by a dukun beranak. 10. It is believed that dukun beranak can give physical and supernnatural powers by reading prayers and by chanting mantras for the patient to feel calm and safe: "Usually the mothers still need a dukun beranak to attend the birth because they will feel calmer and the dukun [beranak] can usually chant while spraying betel nut onto the mother's belly" (head of a subdistrict, TTU, NTT). 11. Dukun beranak can raise the position of the mother's uterus through massage after delivery. 12. Dukun beranak do not give women perineal sutures after delivery. Community members are often scared that perineal tears from childbirth will be sutured. In contrast to midwives, who are sometimes required to suture a women's perineum after tears, dukun beranak do not suture. In NTT, they heal the tears through se'i. The SMERU Research Institute 35 13. Dukun beranak are prepared to follow a women's request related to their preferred birthing position: lying down, squatting, or standing. Related to this, the village midwife in East Miomaffo, TTU, NTT explained that midwives are recommended to follow women's requests for delivery position as long as it does not endanger the mother or infant. This recommendation is called "gerakan sayang ibu", literally meaning "care for mother movement". 14. Belief and trust in the tradition of se'i in TTU and TTS. Se'i is done to restore the health of women after delivery and to heal wounds in the genital area. Aside from the pros and cons of using dukun beranak, dukun beranak have an important role in NTT considering the limititations to modern MCH services in the province, especially midwives. Trained dukun beranak always make an effort to communicate with village midwives. In urgent situations, they will accompany a patient while waiting for the midwife to arrive, and if necessary, they will assist with the delivery process. Later, they will remind the patient to have their health conditions monitored by the midwife. In communities in West Java, although there are traditional beliefs related to women's prenatal and postnatal health and delivery practices (see Appendix 19), the beliefs do not influence their use of modern MCH services. Actually, some no longer believe in or follow the traditional practices. In various discussions on the matter, it emerged that the community is aware of the importance of nutrition during pregnancy and after delivery, as well as the importance of exercise andphysicalactivity, particularly whennearing labor. Other mores that have the potential for impeding the function of midwives are the belief that the husband alone should assist with the delivery of the first child and the taboo for a man's wife's genitals to be seen by another person. This is the case in Taunbaen village, North Biboki, TTU, NTT. In such cases, the village midwife attempts to explain that a midwife is necessary to help with the delivery process and does not attempt to prevent the husband or other family members from being present. 3.2.5 Actors that Influence Demand for Modern MCH Services The role of the local government. The good community knowledge and awareness of the importance of MCH services are partly due to concerted efforts by the local governments at the district/city, subdistrict, and village levels to encourage the community to use modern MCH services. The Sumedang District Government, for instance, developed the "Tri Mitra" program in an effort to embrace paraji and communities still using their services. The program delegates prenatal and delivery care tasks and functions between midwives, paraji, and posyandu cadres. Policy implementation is strengthened by pangloh, or fines, for those who do not involve one of the three service providers during the delivery process. Although they do not have a clear understanding of the amount of the fine (according to the local puskesmas head, it is only Rp50,000, but some community members believe it to be as much as in the millions of rupiah), the community has become more inclined to use midwives rather than dukun beranak. Sumedang District Government has also established a policy to make puskesmas services free, which has also attracted community interest in the services, including the puskesmas MCH services. The community is not yet satisfied with the policy's implementation, criticizing the long queues and stating that the same medicine is offered for all kinds of illness. However, the policy has broadened community access to modern MCH services. The development of Desa Siaga is another policy; for example, in Pamekaran village, the 36 The SMERU Research Institute village officials have started to collect a fee of Rp1,000 per family for assistance funds for complicated deliveries. In Cirebon District, the local government has applied a policy for institutional development at the village level; in fact, in several villages, these institutions go down to the RT level. For example, in Jagapura Kidul, Gegesik Subdistrict, there is a village health center, or Pusat Kesehatan Desa (PKD), that runs every Thursday, while in Kelurahan Mundu Pesisir, there is a health clinic, or balai pengobatan (BP). Paraji are also involved in routine quarterly puskesmas meetings and in Cirebon District, preparations are also now underway to form Desa Siaga. The role of village officials. Village officials should be the most influential actors in raising community awareness of the importance of MCH. Nevertheless, their activities and roles vary between villages, leading to differing awareness levels between villages. As an example, the Sumedang District Government's policies are well-implemented at the village level. In Cirebon District, the role of village officials varies. In Gegesik Kulon village, Gegesik Subdistrict, village officials such as bekel (the hamlet head) and lebe (welfare section head) always make themselves available to attend the posyandu and go from house to house to pick up community members and take them to the posyandu if they have not already been present during that session. In NTT, village heads, hamlet heads, and posyandu cadres always monitor who has not yet obtained MCH services. They always make themselves available to visit posyandu and see that polindes are in place. There are even several village heads who have organized their residents to build a polindes and a simple house for the midwife. Village officials also issue fines of Rp2,500­Rp5,000 to community members who do not attend the posyandu, with the village midwife and posyandu cadres realizing the collection of the fines in the field. It is not yet clear whether community awareness of the importance of attending posyandu is a result of a real understanding of the importance of MCH services or simply a matter of attending in order to avoid being fined. However, when the community experiences the benefits, eventually a real understanding should emerge. The women in several sample villages acknowldeged that they always make the effort to go to the posyandu because if they do not, they will be fined or will upset the midwife. The role of health workers at the village level. Posyandu cadres are highly active in urging the community to go to the posyandu and, together with the midwife, explain the importance of MCH services. Posyandu cadres are a source of information about MCH and help and information about general health, as acknowledged by FGD participants. As previously mentioned, posyandu cadres hold a central position in urging the community to use modern MCH services, and are an outlet for the community to share their concerns or ask for advice about as well as help in social matters. Role of religious figures and tokoh adat (experts in local customs). The role that religious figures and tokoh adat play in pushing the community to use MCH services cannot be overlooked. In West Java, kiai25 are central community figures and often influence their followers to use health services in various sermons or teachings. In fact, one kiai in Nagarawangi, Sumedang is the main figure in the "Clean and Healthy Rancakalong" movement. Priests in NTT also have a similar role in encouraging the community to use MCH services as well as spread the information regarding these services. Of course, there are still some religious figures who do not support MCH programs, mainly on issues related to 25 Kiai are religious leaders among Muslims. The SMERU Research Institute 37 family planning. Their reasons for this are that the program contravenes the religious doctrine, but this problem does not emerge in the communities. Tokoh adat, particularly in NTT, also have a role in urging women to use particular MCH services. While their role is not too apparent because their number and significance are on the decline, in several areas such as North Biboki and Batu Putih, their role is clearly evident in the formulation of village regulations on fines for women who do not use MCH services. The role of family. At the community level, demand for MCH services is highly influenced by factors within the family. In West Java, decision making patterns for the use of modern MCH services are colored by groups of wives and supported by their husbands and parents or parents-in-law. Some parts of the community also admit that their decision to choose which type of MCH service they will use during their pregnancy or for delivery is the result of a joint agreement between husband and wife. In NTT, family actors, particularly the husband and extended family (parents, parents-in-law), play an important role in the decision for prenatal, delivery, and postnatal care. Of course, the family's decision is much influenced by their knowledge and awareness of modern MCH care and that knowledge is also influenced by posyandu cadres, friends, and neighbors. Nevertheless, this kind of external influence is not always followed by increased awareness of the importance of modern MCH services. Such change also depends on poverty levels which are also tightly connected to education levels. As an example, Cirebon District, with a poverty rate of 16.6%, is poorer than Sumedang District, which has a poverty rate of 11.7% (BPS 2004 data). This difference may help to explain why Sumedang has a higher level of demand for modern MCH services than Cirebon. Community social organizations and nongovernment organizations. In some areas, community social organizations are involved in MCH activities. During the research, in Sumedang, SMERU researchers came across women from the PKK who were active in ensuring the success of the MCH program through their assistance in the preparation of the Desa Siaga program at the village level. In efforts to ensure the success of endeavors to improve nutrition in NTT, since 2002, international organizations such as Care International and World Vision International26 have routinely provided food and milk aid to malnourished and severely malnourished children, particularly in Oenenu village, East Miomaffo. Aid from international organizations and the provision of supplementary food have apparently caused community members to "empoverish themselves" in order to receive assistance. The food is consumed by the entire family, whereas it is actually only intended for children suffering from undernutrition, malnutrition, and severe malnutrition. This problem is described by a midwife from Batu Putih, TTS, NTT. There was a supplementary food program for undernourished and malnourished children that lasted for 90 days. Residents were given packets of dried food. Here, if mothers are instructed to cook for their child, they think it is something that wastes time, consuming their work time: work in the plantation, the rice field, or wherever. So, we made the dried packets. Gave them eggs and formula. We have given information that each day a child 26 It is often abbreviated to WVI and Indonesianized to Wahana Visi Indonesia. 38 The SMERU Research Institute must eat one egg. However, as it turned out, it wasn't just the child that was eating it, the whole household would share it. Formula was actually being drunk by the whole household. Problems associated with food assistance were also observed at one posyandu in Sekon village, TTU. At the time, the parents were quarreling because they considered that the milk distributed as supplementary food assistance was not evenly distributed. As it turned out, ineligible community members were actually receiving the milk assistance. The SMERU Research Institute 39 IV. SUPPLY OF AND DEMAND FOR BASIC EDUCATION SERVICES According to the latest data gathered to assess Indonesia's performance towards achieving the MDGs in 2007, for the second goal of achieving universal basic education (UNDP-Bappenas 2007), several national indicators (NER­net enrollment rates, GER­ gross enrollment rates, and literacy rates) are tending to improve (Table 7). However, if seen from NER and GER for junior high school, many children aged 13­15 are not continuing their schooling to junior high school. The NER and GER for junior high school in NTT are lower than those in West Java. Other indicators that are used to determine achievements in the basic education sector are attrition levels, graduation levels, and repeat rates. Data from the UNDP-Bappenas (2007) shows that the proportion of students who completed primary school in the 1993/1994 academic year to the 1999/2000 academic year was 73% on average. This figure improves from year to year; however, change is occurring very slowly, as shown by the fact that the proportion of students who finished primary school from the 1999/2000 academic year to the 2005/2006 academic year averaged at 75%. Table 7. NER dan GER for SD and SMP, and Literacy Rates (%) Indonesia NER GER NER GER Literacy Rate and Province SD SD SMP SMP Indonesia (national) - 1992 88.7 102,0 41.9 55.6 96.6 - 2006 94.7 109,9 66.5 88.7 98.8 West Java - 2006 93.0* n.a. 60.0* n.a. n.a. East Nusa Tenggara - 2006 92.0* n.a. 49.0* n.a. n.a. Source: Report on Achievements of MDGs Indonesia 2007 (UNDP-Bappenas 2007: 25­28) Note: * estimate from a graph in Figure 2.4; n.a. = data not available While repeat rates have experienced a decline, the figures are still quite high. The attrition rates have increased between the 2001/2002 and the 2005/2006 academic years (Table 8). Tabel 8. Repeat Rates and Attrition Rates (%) Academic Year Academic Year Repeat and Attrition 2001/2002­2002/2003 2004/2005­2005/2006 Rates Number of Number of % % Students Students Repeat Rates 1,368,163 5.9 1,026,275 3.9 Attrition Rates 683,056 2.7 824,684 3.2 Source: Report on Achievements of MDGs Indonesia 2007 (UNDP-Bappenas 2007) From the above developments in the achievement indicators for the education sector, it is clear that there are still great challenges to be faced on both the supply and demand aspects. The following section will explain the conditions of supply of and demand for basic education facilities in a number of districts in the sample provinces. 40 The SMERU Research Institute 4.1 Supply and Coverage of Basic Education Services 4.1.1 Supply and School Capacity The positive impact from the government policy to build SD Inpres27 in all corners of the country is evident from the availability of state primary schools in most villages in Indonesia. However, this is not true for the majority of villages in NTT. As noted in Chapter 2, in West Java, each village, both rural and urban, has at least two to three state primary schools on average. However, in NTT, particularly in rural areas, each village has an average of one primary school, the majority of which are not state schools. Falas village in TTS, which is in a mountainous area with fairly difficult access, was the only village from the ten of the rural sample areas that had three state primary schools. Most primary schools in the majority of villages in NTT are private religious schools, dominated by Catholic primary schools. The others are SD GMIT (Gereja Masehi Indonesia Timur--Protestant Christian Churches in Eastern Indonesia). As an example, of the six research areas in TTU, only Taunbaen village has a state primary school, namely the combined primary and junior high schools in Oenale. Quantitatively, the presence of one primary school in each village is considered to be sufficient. However, qualitatively, facilities for teaching and learning activities and school infrastructure in West Java are still insufficient and in fact, in NTT, the situation is more dire. In Cirebon, there are not enough classrooms in several primary schools, leading to the necessity for class exchanges between grade 1 and grade 2 or overcrowded classes in favorite schools. Apart from that, there are many classrooms that are in an unusable state, such as broken down ceilings and unmaintained school benches that put the comfort and safety of students at risk. Several primary schools do not have a library, or if they do, they are in a poor condition and do not have a comprehensive book selection, especially for textbooks. The same is true for visual aids and sporting equipment, which are not enough in each school. Whereas in West Java almost all primary school and junior high school buildings are permanent, the same cannot be said for NTT. In NTT, there are still many schools, particularly primary schools, which have thatched roofs, woven fibre walls, and dirt floors. These conditions were particularly evident in Hauteas village, North Biboki, TTU and Falas village, Kie, TTS. Unlike the number of primary schools, the number of junior high schools is still considered to be insufficient although the teaching and learning facilities and school infrastructure are better than for primary schools. State junior high schools are generally located in subdistrict capitals, both in West Java and NTT. In West Java, there are an average of more than three junior high schools (or equivalent) at the subdistrict level, while in NTT there are only an average of one or two. Great distances to junior high schools or their equivalent mean that they are unaccessible, leading to the need for schools that are closer to villages or a greater number of schools. Under normal situations, primary schools have sufficient capacities and some primary schools in rural areas are even short of students. Problems emerge when the majority of the community living in urban areas choose one particular "favorite" primary school over the others that are available. Consequently, classrooms in the popular school 27 To achieve high primary school enrollment rates, a large number of SD Inpres (primary schools constructed based a presidential instruction) were built throughout the country in 1974. The SMERU Research Institute 41 become overcrowded, while the other schools experience a shortfall in student numbers. As an example, in Mundu Pesisir village, Mundu, Cirebon, the community tends to favor SDN (Sekolah Dasar Negeri) 3 (State Primary School 3). Another example is that at SDN Gegesik Kulon 1 and 2 which are adjacent to each other in an urban area in Cirebon, more community members choose SDN 2, and consequently, there are 70­80 students in grade 1 in one classroom. The community did not explicitly state their reasons for choosing the favorite primary school, but in discussions on satisfaction levels, it becomes clear that community choices are generally related to the quality of service that the school provides and the achievements that it has obtained. In addition, as a participant in one of the FGDs explained, she chose SDN 3, the favorite primary school in her village, because of "safety", that is, students do not have to cross a busy road: "It is close to home, Ma'am! They don't have to cross. If they had to cross, I would be worried. It would be troublesome" (Women's FGD, Mundu Pesisir, Mundu, Cirebon, West Java). Issues surrounding capacity also occur in rural areas that have primary schools in each hamlet. Due to distance, more people choose the primary school in the closest hamlet, while there may be a better primary school in another hamlet. Some schools have only 10­20 students, whereas according to the regulations, they could contain 35­40 students. None [was refused due to lack of capacity]. The little ones are still accepted. It doesn't matter if they are treated not as real first graders. In Cakrawati, there are three children who are still young and should still be in kindergarten. (Women's FGD, Sukaratu, Darmaraja, Sumedang, West Java) None [who refused due to lack of capacity], Ma'am; in fact, those who are 5 years old are also accepted to motivate others to enroll. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) Here, there is a large capacity, but there are few applicants. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) The problem of limited school capacity also occurs in popular junior high schools. Although in several areas, there are junior high schools in villages other than the subdistrict capital, the community is generally more interested in the schools in the subdistrict capital. Apart from the status as a state school, another reason for this is that the school is popular, even though it is far away, even up to 5 kilometers. "Parents sometimes hope that their child will go to a favorite school," said one father from Mundu Pesisir, Mundu, Cirebon, West Java (Men's FGD). In order to overcome the problem of limited capacity, in several areas, school management has created enrollment criteria, for instance, age criteria for primary school students that exclude children below the age of seven years and junior high schools that only receive students whose test scores are in accordance with the schools' standards. In the villages around Jagapura Kidul, the village administration has prevented students from going to the main junior high school in the subdistrict center and instead requires them to go to the new school they built so that the new school is not short of students. In almost all areas, children with mental disabilities are also refused enrollment in primary school. In NTT, the school also requires "birth certificates", usually from church groups, to ensure the background of the parents of applicant students, and those who can not provide this certificate will not be accepted: 42 The SMERU Research Institute ... If we reject some, it is because they do not fulfill the criteria. Enrollment criteria are that the child who is enrolled is of school age, that is, six or seven years old. The second is to have a birth certificate. The certificate does not have to come from the civil registrar, but the one from the church will do. Those who do not have a birth certificate are not instantly rejected, but are given the opportunity to make one first. (Principal (male) of one primary school in North Biboki, TTU, NTT) Apart from the regular formal schools above, in several areas, there are still actually equivalency program schools like open schools and Kejar Paket A, B, and C.28 However, various interviews with the community revealed that the community is not particularly aware of the irregular schools and hence, these schools do not become an alternative for their children's education. Some also acknowledged pride (gengsi) if you had to educate a child at the alternative school. As one women's FGD participant from Susukan, Cirebon, West Java states, "If [our children go to] an open junior high school, although it is free, many do not want to because of their pride; it makes children feel inferior." Nevertheless, in Pamekaran village, Sumedang, West Java, the village officials, school managements, and school committees all frequently mentioned Kejar Paket B. Currently, the provision of Kejar Paket B studies has stalled due to a lack of funding, so this year's primary school graduates who did not go on to junior high school and enrolled in the Kejar Paket B program were yet to begin their studies at the time of the fieldwork. In NTT, for the past two years, governments and communities have made a concerted effort to overcome the issues of distance and isolation by building combined primary and junior high schools (SD-SMP Satu Atap, or SATAP) and "small primary schools" (SD Kecil). The combined primary and junior high schools concept means that children who graduate from primary school can continue their education at the same location. This eliminates the problem of distance and physical access for the community. Almost all subdistricts in TTU and TTS now have a combined school. According to an officer from the education office, the effort will be made to develop a combined school in each subdistrict in NTT, particularly in the more remote subdistricts. No less important than the government's effort, communities' efforts have also been initiated to find a solution to the problem of access limitations by building small primary schools. "Small primary school", or SD Kecil, is the term the local community uses to refer to a remote class of the main school. They are established in remote areas or areas with difficult access. However, unfortunately, such schools have only been established in Hauteas and Taunbaen villages. 4.1.2 Obstacles that Schools Face in the Provision of Comprehensive Education Facilities The main obstacle faced by popular schools and schools that have a number of damaged classrooms is a lack of resources, in terms of both funding and human resources, to increase capacity and improve the school's physical condition. As they have no choice, a number of primary schools accommodate high numbers of students, exceeding their class capacity and resulting in disruptions to the learning process, a lack of concentration among students, and poor teacher supervision of students. Based on information from a school committee member in West Java, government funding is also limited, so the school committee must take special fundraising measures in order for school buildings to be improved. 28Kejar Paket is a school designed for those who do not continue to formal schools. Kejar Paket A is equivalent to primary school, Kejar Paket B is equivalent to junior high school, and Kejar Paket C is equivalent to senior high school. The SMERU Research Institute 43 Schools with small numbers of students also often complain about lack of funding, as without such funding, they cannot provide satisfactory education services. Schools currently rely solely on the government, through BOS (bantuan operasional sekolah-- Operational Assistance for Schools) funds, in order to meet facilities and infrastructure needs. With low student numbers, the school receives little BOS funds and hence is unable to provide standard teaching and learning activities. In addition, since BOS has been available, the understanding of `free school' has made it hard to ask the community to contribute to school funding. The BOS program does not automatically attract parents' interest in sending their children, particularly, to junior high school as it does not cover associated school expenses, such as uniforms, transportation, and snack money. It has been acknowledged that there are still problems with school funding under the BOS program and that actually it is more difficult as funding contributions from communities tend to be lacking. To date, BOS funds are used to fund 12 components, including enrollment/accepting new students, stationeries procurements, teaching equipment, teachers' professional development, funding extracurricular activities, worship equipment, procurement of school furniture, and reporting. Another key obstacle for schools is a lack of teaching staff, particularly teachers for specific subjects. In West Java, the majority of teachers for both primary and junior high schools are civil servants, while in NTT the majority are nonpermanent teachers (guru honorer). In some schools, as found in Oehela village, Batu Putih, TTS and Oenay village, Kie, TTS, there are only two civil servant teachers. This influences the level of teachers in class during teaching hours as well as teacher attendance levels. Schools in NTT generally suffer from a lack of teaching staff, some even not having a mathematics or science teacher, while primary schools in West Java have a shortage of English teachers for grades 4, 5, and 6. Susukan Subdistrict, Cirebon has only 35% of the required number of teachers and consequently, many schools need class teachers and teachers for religious studies and sport. To illustrate, only 5 of the subdistrict's 27 schools have a religious studies teacher and a sport teacher. In several schools, teacher stortages are handled by recruiting senior high school graduates or D2 (two-year diploma) students as nonpermanent teachers. Low teaching quality is another problem. The majority of teachers, particularly primary school teachers, do not hold a bachelor's degree. Moreover, many parents complained that often the teachers do not have good teaching capacities. To improve their teaching quality, as well as their prosperity, several teachers have received the opportunity to continue their education and become certified. However, teachers must fund these activities themselves and several teachers have chosen not to undertake the certification process as they are approaching retirement age. They thus are reluctant to improve their education as for them, it is a waste of their funds. Besides this, some teachers, mainly in NTT, consider the certification requirements to be quite demanding and irrelevant to the education situation in their region. Other obstacles are the poor condition of school buildings (damaged or heavily damaged) and a lack of facilities and infrastructure such as books, art and sporting equipment, library, and laboratory. In several schools, the tables and chairs, and toilets are in an unacceptable state. Scarcity of clean water facilities is a separate obstacle. In certain seasons, schools rely on clean water from a well, but there are often no wells 44 The SMERU Research Institute close to a school, so sanitation is lacking. In NTT, the lack of water means that students are actually asked to bring water to school each day to provide water for the toilets. An absense of administration staff in primary schools, unlike in junior high schools, means that teachers are also burdened with administration management. In schools with few students, perhaps this does not cause too great a problem. However, in schools with many students, for instance those with more than 400 (as is the case in SDN 2 Jagapura Kidul and SDN 3 Mundu Cirebon), administration becomes a large problem burdening teachers. 4.1.3 Obstacles that Teachers Face in Providing Sufficient Services The main obstacle that teachers face is a continuously changing curriculum. When the 2004 Competency-based Curriculum replaced the 1994 curriculum and was still being adopted by teachers, it was again replaced with the 2006 curriculum (KTSP--kurikulum tingkat satuan pendidikan/school's self-developed curriculum), which requires each school to create their own curriculum standards according to a set of national general guidelines. This requires adaptation, particularly in getting a thorough command of the materials, and results in a greater workload for teachers. This is compounded when the application of a new curriculum is not followed by training for teachers. And in reality, almost no training is held for teachers due to a lack of funds; if training is provided, it is usually related to the implementation of a national program and only some teachers participate: A male teacher at one primary school in Gegesik, Cirebon, West Java describes, "Another problem that is also serious is curriculum change. These changes make it difficult because the current curriculum is difficult to apply in a school such as ours because there are so many limitations, like school capacity, teachers, students, and the parents themselves." The low prosperity of teachers often means that teachers only teach because it is their job, not because they feel a "calling" to be an educator; as a result, they teach only a bare minimum amount of material, sacrificing the quality of the lessons. This is compounded by a lack of comprehensive facilities for maintaining teachers' health, mainly for nonpermanent teachers. The level of discipline in NTT amongst nonpermanent teachers is particularly low, caused by the appalingly low pay incentives which range around Rp100,000 to Rp150,000 per month and resulting in a lack of committment in their teaching. In addition, teachers' committment is worsened by the fact that they also have to look for additional income in order to fulfill their families' needs: Their wages are only around one hundred to one hundred and fifty thousand per month. That is certainly not enough. With wages such as that we also cannot fully reward their loyalty because they must fulfill their family needs. So, many teachers are absent as often as they please; in fact, some don't come for a week at a time. But, we also cannot hand out disciplinary punishment to them because they can go just like that and we won't have a teacher anymore." (Principal (male) of one primary school in Batu Putih, TTS, NTT) These difficulties are even worsened by transportation obstacles as almost all teachers do not live in the village where they teach. There is even a teacher in Insana Subdistrict who lives in Kefamanu (the TTU District capital), which is 25 kilometers away from the school and lacks public transportation to the school or village. As a result of such obstacles, teachers are often late, in the rainy season sometimes arriving at the school at around 11:00 and only going to fill in the attendance sheet. Such issues have a poor influence on the quality of education services. The SMERU Research Institute 45 It is a real dilemma that on one side, teachers must recover from falling behind as a result of the curriculum change and students' poor comprehension, while on the other side, they only have a limited education (only few have graduated from tertiary institutions) and do not have a sufficient level of prosperity. Although direct observation in the field showed that teachers usually live in a permanent housing of a higher standard than most and they may have a motorcycle, it appears that the teachers obtain these conditions by using credit facilities. It is easy for teachers to obtain credit as they only need the guarantee of their civil servant decree. As a portion of their wages are docked for credit repayments, most teachers only recieve a small amount of their monthly wage. In the end, teachers experience financial hardship and are unable to pay for their daily transportation to and from school. Teachers (and schools) also face low levels of parental awareness of and interest in their children's education. Parents are still inclined to grant their children's desires, leading to less than optimal study results. Parents also do not take interest in the lessons that their child receives at school or in ensuring that their children receive enough nutrients to concentrate through the day. Many parents still involve their child in family economic activities, mainly in the agricultural sector (during harvest time), fisheries (when at sea), and trade. Teachers also face problems related to students who find it difficult to follow their lessons. Apart from the frequently changing curriculum, a lack of proper nutrition means that students find it difficult to concentrate. To overcome this, in NTT, additional lessons are given in the afternoons, and even at night. In addition, teachers give additional remedial studies and tutoring for students who have fallen behind. In SDK Sekon, for instance, up to three teaching sessions are held each day: morning classes (07:00­13:00), afternoon classes (15:00­16:00), and evening classes (19:00­20:00). A lack of teaching aids such as books, visual aids, and a laboratory compounds these difficulties. If in fact the facilities are available, the numbers are usually very limited and they are in poor condition or out of date.29 4.1.4 Obstacles in Reaching Specific Groups In general, schools do not experience problems in getting certain groups to send their children to primary school. However, this is not the case for junior high school. The specific groups in question are (1) fishermen, (2) poor households/ communities, (3) communities in isolated and remote areas, (4) communities that still revere the customs (adat), (5) those who do not see the benefit in education and who feel apathetic about their future, (6) parents of girls, and (7) disobedient or delinquent children. There are different reasons as to why these groups are difficult to reach. Fishing groups go to sea at certain times, taking their children. Poor households find it difficult to find the funds for associated school expenses such as transportation costs, clothing, and money for snacks. One man from Susulaku, Insana, TTU, NTT explains that some children do not go to school in order to "help the parents. Their parents are disabled. There is a child aged 10 years who does not go to school at all. They have an older sibling of 16 years. They also don't go to school." (Men's FGD) 29 After the interview and observation at one junior high school, the researcher had the opportunity to meet with a geography teacher who asked about the latest map that they needed to teach. The map they currently use was printed in 1970. 46 The SMERU Research Institute Families living in isolated and remote areas face problems such as poor roads infrastructure and lack of transportation or high transportation costs. Communities that still revere the customs are difficult to reach if the child's involvement in school activities conflicts with their customary obligations or interests. For example, in NTT, if a girl goes to school outside the area and stays in a boarding house, unchaperoned, their bride price, or belis,30 will fall because their reputation will be tainted as a result of a presumption that she is not "pure" anymore. Those households or communities who cannot see the benefit in having an education are also difficult to reach. Relatively well-off households may not send their children to school. Such attitudes may be the result of not having a role model in their area who has become successful due to being educated. Apart from issues related to the customs, girls are also difficult to reach as gender bias is still in place, where people will prioritize education for boys. It is also very difficult to make delinquent children go to school due to the environment and lack of parental attention; they are more inclined to play than go to school. 4.1.5 Service Quality Communities living in an area with only one school have no other choice but to send their child to that school even though its facilities and infrastructure are limited and the services are unsatisfactory. Perhaps because they have no other choice, it is difficult for the community to evaluate the quality of the school and its teachers. Because of this, usually, after a reasonably lengthy probing process, the community could finally express the criteria that determine the quality of a school. It was also difficult at first for them to express which criteria are important for a good teacher. It is not clear whether these difficulties were because the community did not usually have critical opinions or suggestions, because they were afraid, or because they did not actually know. The opinions regarding the qualities required for a good school and a good teacher are also explained in Appendix 20. According to community perceptions, the criteria of a good school are related to the school's environment and social activities, discipline of both teachers and students, academic achievements and achievements in other activities (sport, arts, Scouts), graduation rates, acceptance levels of graduating students in schools of the higher level, teachers' teaching and creative abilities, success level of graduates, school-teacher interaction, and the physical condition of school buildings and comprehensiveness of facilities and infrastructure. Criteria for a good teacher are related to their teaching abilities, having a good understanding of and ability to deliver the topics taught, teaching methods, discipline, attitude, and character (wise, kind, not leaving the class while classes are in progress, pious, and being a good role model for students). Some parents are unconcerned about the quality of primary school as measured according to the above criteria as they choose a school not based on quality, but rather on location and safety. The majority of parents are satisfied with the quality of junior high schools, while based on their own evaluation of the quality of primary school teachers, some parents are unsatisfied as the teacher is often late, has a bad attitude (occasionally hitting students), cannot teach, and often leaves the class during class times. The majority of parents are unaware of the quality of junior high school teachers as the school is generally far from their home, while several parents suggested that the teachers 30 Belis is the sum of money and gifts that a bride's family requests from the groom's family when they are to be married. The higher the physical and moral "quality" of a woman, the higher the belis that the bride's family may request from the groom's family. The SMERU Research Institute 47 cannot teach and are uncreative, bad-tempered (some even hit students), and often leave class. Several accounts are listed below. I am also satisfied because the results are already evident: My [primary school-aged] child has become clever. (Women's FGD, Sukaratu, Darmaraja, Sumedang, West Java) All the teachers are good; only they don't live close to the school so they are difficult to monitor. We as parents regret that the principal rarely comes. Only four times a week. On Monday, they come and on Tuesday, they don't come. The principal is always late. We as parents are not satisfied. (Women's FGD, Kuanek, East Miomaffo, TTU, NTT) Personally, I am not satisfied because my child who is in grade 5 cannot read yet. I don't know if my child is stupid or the teacher is no good. Instead, I become embarrased and worried. But evidently, the teacher is inattentive and does not focus on slow children. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) I'm not satisfied because the teaching staff still uses primary school teacher. They don't have any teachers teaching certain subjects. (Men's FGD, Boentuka, TTS) [I'm] not satisfied with my child's homeroom teacher. He has hit my child, but I didn't get angry or hit the ceiling. (Men's FGD, Oenenu, East Miomaffo, TTU, NTT) A child who is polite to their parents or has good behavior will have greater knowledge. (Women's FGD, Sukaratu, Darmaraja, Sumedang, West Java) [I'm] satisfied because many of the teachers have studied [at the university]. Four of them have studied. (Women's FGD, Taunbaen, North Biboki, TTU, NTT) The teachers of grades 1 and 2 are often chatting." (Women's FGD, Bojongloa, Buahdua, Sumedang, West Java) Based on the results of direct observation in several schools, it is clear that teacher absenteeism is high. Several classes appeared to be empty, without a teacher, while several teachers were sitting in the teachers' room. In contrast to the direct observation, according to informants, teacher absenteeism is low, at less than 2 days per month. If a teacher is absent, it is usually because they are sick, attending refresher courses or training, or because of family requirements. Another cause for teacher absenteeism is living far from the school. 4.1.6 The Role of Actors and Community Participation in Supplying School Facilities Since the BOS program has been in place, community participation in the supply of school facilities has fallen, but in isolated areas in NTT, community participation is still very high. Because the community in NTT is highly aware of the importance of school and the physical limitations to accessing school, some communities in NTT actively participate in the supply of education facilities and infrastructure. Through pure community initiative, many communities (such as Oehela, Falas, and Oenay villages in TTS and Oenenu and Kuanek villages in TTU) have built houses for the teachers. Some have also built all the school buildings themselves, such as the simple structures for the "small primary schools" (SD Kecil) in Hauteas and Taunbaen villages in TTU, while in Insana Subdistrict, TTU, they built a student boarding house. In the face of the high spirit of participation, some communities regret the prohibition of parent participation in school funding: 48 The SMERU Research Institute But, having these BOS funds seems to have killed the committee's creativity. Among the conditions for BOS funds recipients is that schools are no longer permitted to request any kind of financial contribution from student guardians, whereas in my opinion, parents should take responsibility for the physical improvement of schools. Because if they are not burdened by responsibility like now, they also do not feel like they are making a sacrifice, and so they do not highly "value" their children's education. If people make many sacrifices to obtain something then that something will become very valuable for them. (Village head in Batu Putih, TTS, NTT) Some village officials realize their role in helping to supply satisfactory school facilities by their involvement in meetings to discuss school budget plans (RAPBS--rencana anggaran pendapatan dan belanja sekolah) and in their joint fundraising efforts with the school committees to look for additional funds for school operational funding, mainly for schools whose low student numbers result in small allocations of BOS funds. Village officials are also involved in ensuring student attendance by (1) surveying school- aged children, (2) providing parents with information on the importance of school so that they send their children to school, (3) visiting parents who do not send their children to school, (4) explaining that school fees for the 9 years of basic education are now lighter under the BOS scheme, and (5) issuing SKTM so that parents can obtain discounts for school books and other expenses. To date, school committees contribute more to the provision of school facilities through the search for funds to the community rather than to the teaching and learning activities. The majority of school committee functions are solely conducted by the committee leader. The school committee leader is usually a community figure or a former school principal. Committee members are usually men and member numbers vary, with the majority of members consisting of community figures, parents of students, and teachers. In some areas, school committees have an indirect role in ensuring that children go to school by receiving inputs or complaints from parents, teachers, and the school. This feedback can help to monitor the implementation of education services in schools. In one case, a teacher was considered to be too harsh towards their students. The school committee reacted by informing the school management so that they would admonish the teacher in question over theirteaching methods. Various informants gave explanations as to why the school committee was not active. The explanations included that the quality and commitment of committee members are low. Some also considered that BOS funds have had a direct impact on the activities of the school committee, as a result of the committee's understanding that their task is only to look for additional funds for funding school development. In the past, these fundraising efforts were directed towards parents; however, with the introduction of BOS, school management and school committees are prohibited from collecting any fees from the students' parents. A male FGD participant from Fatufetto, Alak, Kupang, NTT states that "the school committee does not exist anymore because we no longer pay school committee money." Other explanations are that the institutional legitimacy of school committees is weak. The school principal receives a decree from the district head for their appointment, while the school committee only obtains the decree from the principal. In fact, structurally, the school committee is positioned on the same level as the principal, as is the case with the president and the House of Representatives. The SMERU Research Institute 49 4.2 Demand for Basic Education Services and Factors that Influence Parents to Send Their Children to School 4.2.1 Community Knowledge and Awareness of the Importance of Education Community awareness of the importance of sending one's child to school is good, as shown in the following FGD participant statements regarding the benefits of school. ... [so that children are] able to read and write, say prayers, have a better future, [and] get a job. (Men's FGD, Buahdua, Buahdua, Sumedang, West Java) ... so that [my child] can read and write. (Women's FGD, Boentuka, Batu Putih, TTS, NTT) ... [sothat children are]abletocount. (Women'sFGD, Oehela, Batu Putih, TTS , NTT) ... so that [my child] can speak Indonesian. (Women's FGD, Falas, Kie, TTS, NTT) ... so that [my child] can speak English. (Women's FGD, Buahdua, Buahdua, Sumedang, West Java) ... [so that children are] able to operate the computer. (Women's FGD, Susukan, Susukan, Cirebon, West Java) ... [so that children are] able to tell right from wrong. (Women's FGD, Fatufetto, Alak, Kupang, NTT) ... [so that children] respect and obey the parents. (Women's FGD, Buahdua, Buahdua, Sumedang, West Java) ... so that [my child is] cleverer that I am [the parent]. (Women's FGD, Susukan, Susukan, Cirebon, West Java) ... so that [children are] better that their parents. (Women's FGD, Naikolan, Maulaffa, Kupang, NTT) Children have to be more advanced than their parents, are able to work, and are not left behind in education; they must benefit from the education. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) "Sending children to school is to fulfill the 1945 Constitution's mandate in order to foster the people's intelligence; parents are obliged to send their children to school although it is costly." (Men's FGD, Mundu Pesisir, Mundu, Cirebon, West Java) ... so that the child's future life is better. (Men's FGD, Oehela, Batu Putih, TTS, NTT) ... so that [children] can become civil servants. (Women's FGD, Sekon, Insana, TTU, NTT) ... to change attitude and mentality. (Women's FGD, Sekon, Insana, TTU, NTT) ... to humanize human beings.... (Men's FGD, Sekon, Insana, TTU, NTT) In my opinion, children go to school to develop the village [in the future]. (Women's FGD, Oehela, Baru Putih, TTS, NTT) 50 The SMERU Research Institute The high level of community awareness of the importance of school has led to almost all parents sending their child to primary school and some parents sending their child to junior high school. As a result, with the exception of disabled children, all children aged 7­12 in the sample areas are enrolled in primary school. In this village, almost all (children) go to school; maybe only 19 buttons31 [who do not go to school]. (Women's FGD, Tangkil, Susukan, Cirebon, West Java) Those who do not go to school are mostly junior high school-aged children. All primary school-age children go to school. (Women's FGD, Sukaratu, Darmaraja, Sumedang, West Java) There are some [children], Sir, about 20%. Of the 20%, about 4% did not register and 16% are dropouts. (Men's FGD, Jagapura Kidul, Gegesik, Cirebon, West Java) There are no children who do not go to school; all of them go to school. (Men's FGD, Parents of primary school-aged children, Naikolan, Maulaffa, Kupang, NTT) Evidently, there are still some six-year-olds that are not yet attending school; however, this is due to the problem of school capacity, children's capacity to retain their lessons, and some children having a disability. In Neglasari village, Sumedang, schools are not willing to receive children under the age of seven years as they consider that children under that age are unable to follow the lessons. In contrast to the above, in Oehela and Boentuka villages, Batu Putih, TTS, many parents have sent their children even below the age of 6 years (3­5 years) to primary school. This has occurred due to the lack of a kindergarten in the villages which accommodates children below the age of seven. One village head (male) from Batu Putih, TTS, NTT explains, "There is no school for children under school age as yet, whereas the community here really wants to put their children into school. As can be seen in primary school, there are children who are only three or four years old, but they are already in grade one." A minority of those who have enrolled in primary school do not end up completing their primary school education or withdraw from school, or after they complete primary school, they do not continue to junior high school, for various reasons. Not all children who have enrolled in junior high school can complete their education, simply discontinuing their studies. The occurrence of withdrawing from primary or junior high school or not continuing from primary school to junior high school is prevalent in all areas in varying numbers between regions (see Box 2). 31 This button method is a means used during FGD sessions in qualitative research to calculate percentages in a population using as many as 100 buttons, a total number of which FGD participants are not aware of. All buttons are the representation of the whole population being researched. The participants are only asked to separate a fraction of the total buttons from the rest of the buttons to estimate the percentage of the population that meets the answer to each question asked by the researcher. The SMERU Research Institute 51 Box 2. Students' Education Discontinuance Withdrawing from primary school With the exception of Neglasari Village, Darmaraja, Sumedang; Taunbaen Village, North Biboki, TTU; and Fatufetto Village, Alak, Kupang, all villages have children who have withdrawn from primary school, some of them in large numbers. In 2007, for example, in one state primary school in Jagapura Kidul Village, Gegesik, Cirebon, 10 out of 69 students from the same intake have withdrawn from school. In one state primary school in Mundu Pesisir Village, Mundu, Cirebon, 3­4 students from the whole school (425 students) withdrew. In two coastal villages in Cirebon (Mundu Pesisir and Mertasinga), where some community members work as fishermen, many boys from grades 5 and 6 have discontinued, while in Tangkil Village, Cirebon, one child withdrew from primary school and moved to a pesantren (traditional Islamic school). Withdrawing from junior high school The study did not come across one single sample region that was free from withdrawing students at the junior high school level and in NTT, the tendency was high. As an example, during the 2006/2007 school year, 14 students (or around 4%) had withdrawn from SMPN 2 Insana, TTU, and in the same school year, five students withdrew from SMPN 2 of West Amanuban, Batu Putih. Not continuing to junior high school One of the successes of the Nine Years of Compulsory Basic Education policy and various other education programs, for example BOS, is the reduction in the number of students who discontinue their schooling. To illustrate, in Oehela Village, Batu Putih, TTS, the community estimates that a maximum of 1% of junior high school-aged children have not enrolled in SMP. This estimation is supported by information given by informants that all of the 2007 primary school graduates have enrolled in the junior high school. The proportion of students who do not continue to junior high school tends to be lower in urban areas than in rural areas. However, the reverse is true in several other villages. For example, in Pamekaran Village, Sumedang, only 7 of the 13 SDN Cikeusik 2007 graduates are continuing their education at the junior high school. The village officials are still trying to recruit the remaining graduates to the Kejar Paket B program. Not going up to the next grade, repeating, and not graduating The majority of primary school students in each village progress to the next grade. Those who do not are generally students in grades 1 and 2 or those students who do not go up from grade 5 to grade 6 as they do not fulfill the requirements. In 2006, in one state primary school in Mundu Pesisir Village, Mundu, Cirebon, eight students did not go up from grade 1 and six students did not go up from grade 2. In SDK Sekon, Insana, TTU, approximately 20 students were not allowed to progress to the next grade: 9 from grade 1 (5 boys and 4 girls), 5 from grade 2 (2 boys and 3 girls), 6 from grade 3 (3 boys and 3 girls), 3 boys from grade 4, and 8 from grade 5 (5 boys and 3 girls). At the junior high school level, in SMPN 2 Insana, TTU, for instance, 7 from 100 students (or 7%) did not progress from grade 2 to grade 3. In the case of students who did not progress from grade 1 to grade 2; according to the school, this year's grade 1 had more "less intelligent" faces. Unlike the relatively low figures for not progressing to the next grade and repeating, the number of students who do not graduate from junior high school is fairly high. As an example, in SMPN 2 Insana, TTU, in 2006/2007, out of 96 students in their final year, 21 students (or 22%) did not pass the national test (UAN). The results of direct observation in several schools show that the number of primary school graduates is lower than the community estimates. As an example, Table 9 presents the development in number of enrolled and graduating students in SDK Sekon, Insana, TTU. The data indicates that not all students who enrolled in the primary school graduated (see the 1996/1997 cohort that should have graduated at the end of the 2001/2002 school year, or in June 2002). Some of them may have not gone up to the next grade and/or withdrawn from school. 52 The SMERU Research Institute Table 9. Number of Enrolled and Graduating Students at SDK Sekon, Insana, TTU School Year Enrolled Students Number of Graduates F M Total F M Total 1996/1997 16 18 34 1997/1998 16 14 30 1998/1999 13 16 29 1999/2000 13 19 32 2000/2001 14 16 30 2001/2002 6 15 21 2002/2003 16 9 25 2003/2004 13 11 14 2004/2005 9 9 18 Note: F = female; M = male The majority of students who have withdrawn from school or have not continued to junior high school now work. In Nagarawangi village, Rancakalong, Sumedang, many of them work in the small industry of making bags and furniture, while in Tangkil village, Susukan, Cirebon, they become laborers at the roof tile factories. In Bojongloa village, Buahdua, Sumedang, they choose to work as public transportation conductor, while in Jagapura Kidul village, Gegesik, Cirebon, they work as shoe polishers. In fact, some of the children have become beggars in Jakarta at the request/demands of their parents. In Mertasinga village, Gunung Jati, Cirebon, one girl who discontinued school when she was in the sixth grade became a migrant worker at the request of her parents. While the majority of children who withdraw from school or do not continue to junior high school work, some of them become unemployed: "Usually, a lot of them are hanging out together at the market, so [they] become unruly" (Men's FGD, Tangkil, Susukan, Cirebon, West Java). Apparently, some parents in certain areas in NTT are still not aware of the need to send their children to school. Some of them do not see the benefit and importance of school or they do not see that they can have a good future by being educated. A man from Hauteas village, North Biboki, TTU, NTT points out the common feelings of those who do not consider school important: "There's already a bupati, already a subdistrict head, [and] already a village head. Who do you want to replace?" The statement above means, "What's the use of tiring yourself by going to school. Later on, you won't become an official" (Men's FGD, Hauteas, North Biboki, TTU, NTT). The community in this region considers that one's life can only be improved if one's children become an official. Hence, a measure of one's success is becoming an official or a civil servant, or obtaining good employment. Unfortunately, in this research area, it is very rare to find a role model who has achieved their success as a result of their education. The majority of the community who have been to school in the region end up working in the same job as their parents, usually in agriculture or raising livestock, so the perception of going to school as an instrument to change one's destiny has foundered. The SMERU Research Institute 53 Box 3. Conditions for Going Up to the Next Grade For grades 1 and 2 of primary school, students must be able to read, write, and count before they can go to the next grade, and for grades 5 and 6, it depends on their readiness to take the final exam where their scores for Indonesian, mathematics, and religious studies are more than 5. For junior high school, besides meeting the minimum attendance, the other standard criteria for progressing to the next grade are a score per subject of at least 65 and a positive evaluation result of the child's attitude. Currently, in junior high school, a child may repeat twice, but if on the third attempt they again do not qualify to go up to the next grade, they will be promoted to the next grade anyway. Because of a lack of awareness, while some community members are willing to sacrifice several livestock for the requirements of a customary ceremony, they do not want to sell even one animal to pay for their children's school fees. They prioritize the customs over their child's education. This is the case in Insana Subdistrict. According to junior high school teachers, if a community member has a reduced number of cows, for example, to fund their children's education, they will feel that their wealth will be reduced and as a result, their reputation will be lost from the "customs". This is in contrast to when they sacrifice a cow for customary ceremonies; while the number of their livestock is reduced, the loss will be made up in the "customs". Still related to the customs, in North Biboki Subdistrict, TTU, a minority of parents do not want to send their daughters to junior high school as they are afraid that this will reduce their bride price (belis) value. Because the schools are far from the village, female students are forced to stay in a boarding house or dormitory, and their parents cannot chaperone them. To the parents, there is a risk that a girl's reputation will be tarnished if they live away from home. They may mix with boys in a nearby dormitory, or get a boyfriend, have sex, and possibly get pregnant, and so will no longer be considered to be "suci", or "pure", and thus their belis value will be reduced. 4.2.2 Community Choice of and Access to Existing Schools In West Java, the existence of primary school facilities in almost every hamlet has enabled rural communities to send their children to school. The main considerations for choosing a school are that the school has a state school status and it is located close to the home. "I send my child to SDN Darondong because it is close to my house. If I sent them to SDN Buahdua 2, it would be too far. I feel sorry for the kid," said one father from Buahdua, Buahdua, Sumedang, West Java. (Men's FGD) For the majority of parents, school fees are the reason for selecting a specific school. Even though BOS generally covers tutition fees, the community still incurs other expenses such as transportation costs: The school has already been made free, but if the school is far away, so its the same thing because the cost is high. (Men's FGD, Buahdua, Buahdua, Sumedang, West Java) The burden of the fare; we may not be able to afford it, Sir. I feel sorry for the kids if they can't leave for school because they don't have the fare. (Men's FGD, Neglasari, Darmaraja, Sumedang, West Java) 54 The SMERU Research Institute Other reasons for choosing a school are to follow rules or due to safety concerns. In Buahdua village, Sumedang, for example, the village administration has suggested that residents send their child to the closest school, while in Mundu Pesisir village, Cirebon, parents choose primary schools with regard to their children's safety. According to one man from Buahdua, Buahdua, Sumedang, West Java, "The village has suggested that they send their children to the closest school." (Men's FGD) The Buahdua village administration's decision for community members to send their child to the closest school is related to the very low number of students at some schools against their capacity. The success of the Family Planning program in Sumedang District has resulted in a fall in numbers of school-aged children in several villages. This has led to student numbers in several primary schools being lower than the school's actual capacity. According to the regulations, normal capacity per class is 40 students. However, one state primary school in Buahdua village has only 15 students per class. Similar numbers are found in all three state primary schools in Pamekaran village, Sumedang and in SDN 1 Jagapura Kidul, Cirebon. In fact, in Buahdua Subdistrict, which has had the most successful Family Planning program in all of Sumedang District, the junior high school with the highest number of students is still running under its maximum capacity. In addition, all the village administrations in Jagapura (Lor, Kidul, Kulon, and Wetan), Cirebon have adopted the policy that all junior high school-aged children in the four villages are required to go to SMPN 2 Jagapura due to its low student numbers. Because the majority of state junior high schools are in subdistrict centers or are outside the village, rural communities do not have a choice but to sent their child to the closest school, without consideration of school quality.32 This is not the case in regions with several schools, both in urban areas or in rural areas bordering cities. Apart from having far better access, these communities also have several choices. Both of these factors enable the community to begin to consider school quality rather than only distance and costs. However, as a result, better quality and popular schools may suffer from capacity limitations. A small number of those students who do not continue to junior high school are encouraged by officials or schools to take the Kejar Paket B program. However, there are still very few students interested in the Kejar Paket B program, and in several villages, it is not available. In Pamekaran village, Sumedang, as the school is still waiting for funding certainty, this year's Kejar Paket B program will not be running. As a result, this year's primary school graduates who have not enrolled in junior high school are adrift. Unlike in West Java, the limited supply of education facilities in several areas in NTT has implications for the communities' limited choice in schools. In rural areas, parents do not have a choice and must send their child to the only primary school in their village. In urban areas, this is not always the case. In Kupang City, for example, there can be more than one state primary school in a village, so the community has a choice. Usually, they select the closest school. Interestingly, religious affiliation is also a consideration for parents when choosing a school for their child. This is the case in villages with more than one primary school with different religious affiliations, such as Boentuka village, Batu Putih, TTS. As explained by the village head, the village is dominated by Protestant Christians, who usually choose to send their children to SD Inpres Boentuka, while the Catholic parents usually send their children to SDK Yasuari, a Catholic school. 32 This also makes it difficult for communities in almost all areas to express their opinion about school and teacher quality, as to date they have not chosen schools based on their quality, but rather on their ease of access. The SMERU Research Institute 55 For the junior high school level, in general, the community chooses the closest or popular school, both in urban and rural areas. For example, more choice is available in Insana Subdistrict, TTU, which has a state and a Protestant junior high school, but the community chooses the closest SMP, SMPN 2 Insana. In Susulaku village, the community prefers to choose the Protestant junior high school. However, in several subdistricts with only one junior high school (mainly before 2006), such as Kie and Batu Putih subdistricts in TTS and North Biboki Subdistrict in TTU, parents have no choice. It should be noted that "closest" does not necessarily mean that the school is nearby. From most villages, it is roughly more than 4 kilometers to the nearest junior high school, but from others, such as Oenay village, Kie, TTS, it can be up to 10 kilometers. However, since combined schools (SD-SMP Satu Atap) and open schools (Kejar Paket B) have been established in several areas, conditions are changing for the better, to the point where some communities now have a choice. 4.2.3 Physical and Financial Accesses Isolation is the main issue that rural communities complain about as it means that their children are unable to continue their education to junior high school or have no choice but to withdraw from school. Regional isolation is connected to great distance, unfavorable road conditions: poor road conditions, hilly conditions, and muddy roads during the wet season, and sometimes nonexistence of a bridge to cross the river; unavailability of a junior high school in the area, and a lack of transportation facilities. In NTT, children in rural areas sometimes have to cover a distance of 3­4 kilometers to reach their primary school; junior high school students have to travel even further. In Taunbaen village, North Biboki and Oenenu village, East Miomaffo (both in TTU), junior high school students have to travel more than 10 kilometers. Children in Susulaku village, Insana (also in TTU) are slightly better off as the closest junior high school is 4 kilometers away. In TTS, for instance in Oehela village, Batu Putih, and Oenay village, Kie, the students have to travel 4­5 kilometers. In urban areas, distance is not as much of a problem as transportation is widely available. However, in villages in NTT, sometimes great distances cannot be overcome as sufficient transportation facilities are either not available or expensive. Thus, many school children must walk for 2­3 hours. This is a problem not only because it requires a great amount of the children's energy and time, but also because it reduces their enthusiasm for learning and leaving for school. Their concentration is also diminished after such a long journey, more so if they have not been provided with breakfast before leaving. Sometimes it also means that the children do not make it to school, truanting instead. If they do make the effort to go to class, they are afraid that the teacher will punish them for being late. In the end, the problem of distance cannot be separated from the problem of limited financial ability. Families of school children who are unable to walk for such long distances or face distances that are so great that walking takes too much time must provide the funds for transportation costs. Although the problem of distance has been seemingly overcome in several areas that have built a boarding house near the junior high school, this also creates its own problems; children are required to provide their own food and pay their boarding house rent, and the boarding houses can only accommodate a limited number of students. 56 The SMERU Research Institute Limited financial access is the main reason for not continuing education to junior high school and for attrition. According to school management, poor families are received; in fact, in Sumedang, they are prioritized. BOS funding, which can be directed towards tuition fees, has enabled this. Nevertheless, families must still bear the burden of associated school expenses and daily family needs, which now account for problems regarding limited financial access and so lead to attrition and the inability to continue to junior high school. Associated school expenses include transportation costs, purchasing books, LKS (lembar kerja siswa--students' exercise sheets), school equipment, uniforms, and snack money (see Box 4). The economic prosperity or ability of a prospective student is not a criterion for acceptance to school, but when some poor families come up against such associated expenses, they withdraw their child from school. As an example, in several state junior high schools in Sumedang, prospective students are required to pay chair/building money, book money (LKS and some textbooks), and clothing money (uniforms, batik, sport uniform, muslim uniform) which in total range between Rp400,000 and Rp600,000. This is also the case in NTT. Mothers of children at one junior high school must pay no less than Rp700,000 at the start of the school year (see Box 4). Parents' inability to fulfill such high associated education costs sometimes causes embarrassment for children and so they discontinue school: "Some also [discontinue their schooling] because they are embarrassed that they can't pay the book money" (Women's FGD, Jagapura Kidul, Gegesik, Cirebon, West Java). Box 4. High Associated School Expenses One mother in Oehela village, TTS, whose child is in junior high school, provided the following information regarding the associated school costs they incurred for their child's first year at junior high school: 2 uniforms: Rp230,000, 3 exercise books/sheets: Rp75,000­Rp90,000/year, Pencils/pens: Rp22,000/year, 2 pairs of shoes: Rp130,000­Rp140,000, Photocopying: Rp60,000­Rp65,000/year, School committee fees (BP3) : Rp90,000/year, Enrollment fee: Rp5,000 A small amount of BOS funding is kept aside to help less-well-off families to fulfill transportation costs, but in most cases, BOS funds are only enough to eliminate monthly tuition fees. The majority of BOS funds are used for school operational expenses, extracurricular student activities, and the wages of nonpermanent teaching staff. Assistance for poor children is only provided by parties external to the school, for instance foreign donors, such as the biscuits from the Australian Government for primary schools in Batu Putih Subdistrict, TTS; cash grants and scholarships for primary school and junior high school students in North Biboki from the Dutch Government; DBEP (Decentralized Basic Education Project) assistance for school construction and renovation in TTS; and aid from several international NGOs such as Plan International, CWS, WVI (World Vision International), and Care. The SMERU Research Institute 57 A significant number of children are forced to help their parents earn money because of the family's poor financial situation. In NTT, children work as farmers helping in the field or rice paddy, herdspeople, motorcycle taxi operators, public transportation conductors, or peddlers. In West Java, children may also be required to work as fishermen or laborers (roof tile factory laborers, clothing factory laborers, domestic workers, shop assistants), migrant workers, traders and scavengers in Jakarta, or buskers. Some children who have been required to work discontinue their schooling as school time is taken over by work. Others may have felt the "pleasure of money" and so lose the motivation to attend school: "Yes, there are [children who withdraw from school]. Usually, their parents take them to Jakarta. If they have already been to Jakarta, the child knows how it feels to have money, so yes, the child becomes unmotivated to go to school" (Men's FGD, Jagapura Kidul, Gegesik, Cirebon, West Java). In NTT, some parents are not prepared to pay absentee fines their children have accumulated. The majority of districts in TTU and TTS issue fines for children who are absent. The fines vary among the regions. In Hauteas village, TTU, for instance, the fine is Rp1,000 for each day that the child is absent. If the fines accumulate and the parents cannot pay them, the child then becomes the victim and withdraws from school. 4.2.4 Other Factors which Influence Primary School Graduates to Not Continue to Junior High School and Discontinue Their Education Apart from issues surrounding distance and financial access, other reasons why children do not extend their education to junior high school is that they do not want to go to school and they did not graduate from primary school. Attention must be given to reasons why children do not want to go to school. Apart from wanting to help their parents, for example by earning money, they also do not see that they can make a better future for themselves by extending their education. Besides factors such as lacking parental supervision, being undisciplined or disobedient, or being delinquent, they may also not want to go to school because it is difficult for them to retain the lessons, perhaps as a result of a low nutritional intake. Such conditions make it difficult for the children to progress to the next grade and can mean that they do not graduate. Juvenile delinquency appears to occur as a result of environmental influences such as associating with friends who do not attend school, playing computer games such as the Playstation, being persuaded by their friends, and getting little parental supervision: ... because there are a lot of influences ... influence from their outside friends. (Women's FGD, Oenay, Kie, TTU, NTT) The motorcycle taxi driver persuaded them not to go to school. (Women's FGD, Hauteas, North Biboki, TTU, NTT) I've got one like that. Last year, he took Paket C but it was useless because of environmental influences. So, now he goes with the boats. (Men's FGD, Fatufetto, Alak, Kupang, NTT) If a child discontinues their education because the school refuses to admit them, it is usually related to the child's behavioral problems. Most cases are related to behavior leading to pregnancy or drug use. As a result, the child may be embarrassed to continue their education or be expelled by the school. 58 The SMERU Research Institute Information provided by community members and school management shows that a significant proportion of attrition is caused by behavioral issues. School management and village administrations often attribute poor behavior to inadequate parental supervision as the parents are working. In any case, financial problems, parental supervision, and a child's behavioral issues are indeed interrelated, as reflected in the following statement: But, certainly you can't pin the blame on the children. They are only 6­12 years old and aren't yet able to understand the importance of school. Consequently, a lack of a child's desire actually reflects a lack of awareness and motivation from their parents for the child to get a good education. The parents' lack of motivation is caused by their being poor. So, instead of paying attention to their child's education, they are actually looking to earn a living for the family, and so not too much attention is paid to the children. (School principal (male) from North Biboki, TTU, NTT) A lack of parental supervision can be caused by the impact of divorce, the death of a parent, and as a result of entrusting the child to a relative who is unable to give the child full supervision. This is reflected in the following statements from informants: There is one whose father died, so they don't want to go to school. (Women's FGD, Kuanek, East Miomaffo, TTU, NTT) If the mother dies, the father usually remarries and he only takes care of the new wife, not paying attention to the children from the first wife. So, the children do not like to be with their parents again and more often choose to withdraw from school and look for work. (Women's FGD, Oenenu, East Miomaffo, TTU, NTT) As is the case in Jagapura Kidul village, Gegesik and Susukan village, Susukan (both in Cirebon), some community members work in far away places or become migrant workers, so they entrust their children to family members, who may not give their full attention to the child. In Mundu Pesisir village, where the majority of community members are fishermen, usually the parents and young children go on fishing expeditions outside the area, while school-aged children are left with a relative. In Susukan village, Kecamatan Susukan, Cirebon, many cases of attrition at the primary school level are as a result of parental divorce. Another example of combinations of lack of parental supervision and financial pressures are when a child leaves school to go with their parents when they are working outside the region (for example, going to trade in Jakarta). Because of low nutritional intake, a child cannot concentrate enough to follow their lessons. Lack of concentration is sometimes a result of a combination of poor nutritional intake and poor parental care. In most cases, however, financial issues lead to poor nutrition as the family cannot afford to provide sufficient amounts of nutritious food. Financial limitations can mean that a child's diet is limited and does not vary, so children may be reluctant to eat. In addition, sometimes children have to leave for school before their parents have had a chance to prepare food. One teacher shares their experience in teaching children who are undernourished: "... Here we can only seriously teach until ten o'clock. Later than that, we have fun more because it won't go into the child's head, even if you force it. They get tired" (Teacher at one junior high school in North Biboki, TTU, NTT). The SMERU Research Institute 59 4.2.5 Irregular Attendance and Influential Factors The majority of students have never been absent from school for extended periods and have regular attendance, at both the primary school and junior high school levels. Nevertheless, short absences (less than 3 days) were prevalent in all areas for different reasons. Only in Tangkil village, Susukan, Cirebon, parents give their children permission to be absent during the harvest season (for a period of a week). In this village, where the majority of community members work as farmers and farm laborers, the harvest season is considered to be a "blessing", so parents allow their child to be absent from school to help. Most students do not directly help in the field. As both parents will often work in the field, the student will usually look after younger siblings at home or go to the field with the parent as there is no one in the village to look after them. "Here, if there are a lot that don't come, it is always around harvest time, Sir. The problem is that they are helping their parents. It can go for 3 to 7 days. They don't ask for permission because it is already the norm here, " explains a woman from Tangkil, Susukan, Cirebon, West Java (Women's FGD). Illness is the main cause of absenteeism. Only a minority of students are absent from school due to financial reasons, with the exception of Tangkil village, Cirebon (see above). Financial limitations often mean that parents cannot buy a spare uniform for their child. This can mean that a child truants if their only uniform is dirty or damaged. Sometimes parents are also unable to provide money for snacks, resulting in the child not going to school. If the uniform is torn, they don't want to go to school." (Women's FGD, Sekon, Insana, TTU, NTT) There are children that ask for snack money, but it is not given to them; so, they skip school. (Women's FGD, Kuanek, East Miomaffo, TTU, NTT) Sometimes students are absent if they have not completed their homework, as they are afraid of the teacher's reaction: "When they don't do their homework, they are afraid that the teacher will be angry [and so don't want to go to school]" (Men's FGD, Taunbaen, North Biboki, TTU, NTT). A child not completing their homework or other assignments may be the reflection of a lack of parental supervision. It may also be as a result of a combination of lack of concentration, sleeping in, and behavioral issues. In urban areas such as Kupang, computer games such as the Playstation are quite disruptive for both primary school and junior high school students, often causing students to truant. In East Miomaffo, TTU, for instance, many students living in a boarding house or dormitory near the school skip school every Saturday as they need to go home to pick up food. School management does not issue sanctions for those students as food is a primary requirement for the children. According to two teachers: Many children's houses are more than 10 kilometers from the junior high school, so girls usually stay in a boarding house. But, for boys there is no boarding house. So, they board in houses around the school. (Junior high school teacher (female) in East Miomaffo, TTU, NTT) On Saturdays, they are often absent because they have to go home to pick up provisions. (Junior high school teacher (male) in East Miomaffo, TTU, NTT) 60 The SMERU Research Institute In NTT, customary celebrations and "market days" can cause students to be absent. Preparations are usually made for customary celebrations many days before the event and the community often works together to prepare for the festivities until late at night. As a result, children sleep in or are too tired to go to school. In addition, as markets are difficult to access, weekly or monthly market days are an interesting attraction for village residents and their children. Parents usually sell their produce or weaving at the market as well as buy household needs, and children often want to accompany their parents; thus, they do not go to school. Some children are absent because of family matters, that is, because their parents have brought them along to attend family activities, or religious or customary activities, or because their parents have asked them to look after younger siblings while the parents work. There are also students who truant because they overslept, besides other reasons. Issues regarding the school and teachers can also lead to a student's reluctance to attend school. Insufficient or unsatisfactory facilities and infrastructure, poor or unstimulating teaching methods, teacher not setting a good example (often leaving class during lessons, admonishing students in an unacceptale manner, etc.), and the teacher often arriving late can all cause a student to lose their motivation to attend school. [My child is] not happy with the teacher. (Men's FGD, Oenenu, East Miomaffo, TTU, NTT) The teacher is mean. (Men's FGD, Naikolan, Maulaffa, Kupang, NTT) [Children are] not happy with particular lessons. (Women's FGD, Naikolan, Maulaffa, Kupang, NTT) Some parents employ several strategies to ensure that their child regularly attends school, reflecting community awareness of the importance of education. These strategies include asking their children about their activities at school when they come home, checking their homework and lessons, asking about their child to their friends or teachers, or taking the child directly to school. Below are some examples: Usually, their mother asks, `What were you studying earlier? Do you have homework or not?' (Men's FGD, Buahdua, Buahdua, Sumedang, West Java) [Parents] check their lessons. (Men's FGD, Buahdua, Buahdua, Sumedang, West Java) [Parents] monitor [their] children through the children's friends or teachers so that parents are not deceived. (Men's FGD, Buahdua, Buahdua, Sumedang, West Java) If the school is close, you can just check. (Men's FGD, Gegesik Kulon, Gegesik, Cirebon, West Java) [Parents] take them to school. (Women's FGD, Gegesik Kulon, Gegesik, Cirebon, West Java) 4.2.6 Actors at the Village Level that Influence the Community to Send Their Children to School In the family, the greatest initiative to attend school comes from the child themselves. Apart from support from parents, a child's desire to go to school is also influenced by their everyday environment. Most parents consider that it is their obligation to send their children to school, The SMERU Research Institute 61 and so if the child does not want to go to school, parents feel that it is their responsibility to order or force their child to attend, to the point where they may use violence, as admitted by one father in an FGD in Fatufetto, Alak, Kupang, NTT, "[It gets] to the point where I hit him ... Hisheadisbleeding ... But, he still doesnotwant togoto school." However, there are also many cases where the initiative to go to school comes from the child themselves, who are also encouraged by their peers. At the primary school level, it is usually the parents who determine which school the child will attend, but at the junior high school level, usually the child determines which school they will attend usually because they want to go to the same school as their friends. Village officials in several villages also serve to encourage community understanding and awareness concerning sending their children to school by proactively encouraging or forcing the residents to attend school. In West Java, this is particularly aimed at poor families by providing them with SKTM. In Tangkil village, Susukan, Cirebon, junior high school enrollments are directly managed by the school using BOS funding, while poor children who wish to continue to junior high school are directly received by the schools without undergoing an entrance test first like the children from other backgrounds. In the last teaching year, six children from one primary school in Tangkil village received an SKTM to continue to junior high school. The role and concern of village officials are also evident in Pamekaran village, Rancakalong, Sumedang, where village officials and the school committees are well aware of the number of primary school graduates and how many of them who are not continuing to the junior high school so that they can encourage them to take the Kejar Paket B. In Buahdua village, Buahdua, Sumedang, the village administration cooperated with school management to establish the Posko Wajar Dikdas (coordination post for compulsory basic education) to process school-aged children by visiting the houses of parents of school-aged children to ensure that they are all enrolled, except those children with mental disabilities. In Darmaraja Subdistrict, Sumedang, the school management for one state junior high school has a policy to make visits to all the primary schools so that all primary school graduates can continue to the junior high school by extending the application period and seeking explanations for why a student is not continuing their education. In NTT, village regulations formalize encouragement from community leaders. In some villages, there are penalties under the customs that give fines to citizens who do not send their children to school. Apparently, the formulation of such regulations and fines are a local initiative to translate the national stipulation on compulsory education. The high level of school participation here can be caused by the stipulations we made that if there are children of school age who do not go to school, then their parents will be issued a sanction, that is, "Balek Tanah", which is working on school land and then planting the plants that the school needs. This stipulation has been in effect since 2004. (Village head (male) in Batu Putih, TTS, NTT) Nevertheless, the researchers still came across village officials that do not play such a role or who were unconcerned about the low levels of community awareness of the importance of educating their children or about the community's problems, making it difficult for community members to send their children to school. 62 The SMERU Research Institute In contrast to the role of village officials, school committees in the majority of villages are still falling short in efforts to support or urge parents and the community to send children to school. It is suspected that some school committee members also do not yet fully understand the functions and roles of the school committee. Often, school committees only take part in fundraising for school development: Yes. What connnects the teachers with the parents is the [school committee] money. (Women's FGD, Buahdua, Buahdua, Sumedang, West Java) The committee is a representative of the students' parents. They are usually assigned to fundraising, resolving problems. (Women's FGD, Tangkil, Susukan, Cirebon, West Java) The school committee's work is good. They have built the school, renovated it. (Women's FGD, Pamekaran, Rancakalong, Sumedang, West Java) The committee's function is indeed raising funds for school infrastructure. (Men's FGD, Sukaratu, Darmaraja, Sumedang, West Java) The school committee is comprised of students' parents who are trusted to allocate funds for school needs. (Women's FGD, Neglasari, Darmaraja, Sumedang, West Java) As the main function of school committees to date has been fundraising, since BOS funds have been available, many school committees are not fully operational except when signing off on RAPBS reports; several schools still involve the school committee in the preparation of RAPBS reports and in school meetings with parents, both at the start and end of the year or at graduation. Nevertheless, in a few villages, school committees work together with parents and the school to resolve problems related to student learning activities. As an example, in Buahdua village, Buahdua, Sumedang, the game of dingdong (an arcade game that involves gambling) had entered the village. All the children were obsessed with the game and so did not go to school. In the end, parents, together with the school and school committee, created a rule to forbid children from playing the game. In several cases, school committees also have a role in accommodating the aspirations of parents and becoming intermediaries in disagreements between school management and parents. With relation to teaching and learning activities, the management of a school in Tangkil, Susukan, Cirebon involved the school committee in the preparation of the school's curriculum (KTSP) and teaching program. The school committee is also involved in monitoring teachers by disseminating the results of their monitoring to the principal or school supervisor. As is the case with school committees, other community members have a very minor role in the encouragement of parents to send their children to school. Some communities are reluctant to intervene if a parent does not send their child to school and only feel sorry for the children. In addition, it sometimes does not turn out well for those who intervene, as the parent in question may be offended. Hence, the community is reluctant to give their opinion: Well [they] have the heart. [They] don't love the child. (Men's FGD, Buahdua, Buahdua, Sumedang, West Java) The SMERU Research Institute 63 But, what if later they say, `Like you are willing to pay the tuition?' (Women's FGD, Buahdua,Buahdua,Sumedang, West Java) [We are] afraid that they will be offended. (Women's FGD, Buahdua, Buahdua, Sumedang, West Java) [I was] offended. Their older sibling passed away. I worried for 40 days thinking about it. Then, the younger sibling got neglected [and] then withdrew from school. (Women's FGD, Gegesik Kulon, Gegesik, Cirebon, West Java) The physical presence of schools in a region has played a role in generating knowledge and awareness as well as encouraging the community to send their children to school. Formal school in some areas in NTT has been in place since the early 1900s. According to the community, the Biboki and Insana regions have had a primary school since 1928 and a junior high school was established in the 1930s. While not many of the community have experienced education, at least memories about schools and other related issues have taken root in their minds. In addition, the dominance of the Catholic and Protestant religions, which are closely related to a tradition of formal education, have been quite influential. 4.2.7 Other Actors that Influence the Community to Send Their Children to School The district/city government is the main provider of education facilities, both in West Java and NTT. However, they do not play a great role in encouraging parents to send their children to school. Compared to those in West Java, local governments in NTT play a more active role. Across levels of government, the subdistrict government has a greater role in encouraging, even forcing, parents to enroll their child in school than does the district government. The North Biboki Subdistrict Education Office, for example, in 2006 conducted an education campaign for the whole village designed to encourage the community to send their children to school. The subdistrict office head of North Biboki states, "In 2006, we held an education campaign in all the villages. It tried to increase awareness, while for problems with facilities, we can only make suggestions." In addition, the subdistrict head of East Miomaffo applied an inducement policy that involves issuing fines to parents who do not send their children to school. The subdistrict head of Insana even asked that people who are aware of a child who is not attending school report it to the subdistrict office for further processing by the police. Although in practice this has not occurred, the policy has resulted in an increase in the number of community members who send their children to school. NGOs, particularly international NGOs, and both unilateral and multilateral donor institutions also play a role in encouraging parents to send their children to school, but this was only found in NTT. WVI, for example, provides aid for both education and health in almost all regions in NTT through programs such as the Caring Parents (Orang Tua Asuh) program which is funded by a foreign donor (Canada). This program not only provided financial support, but also moral support, so that parents would send their children to school. 64 The SMERU Research Institute Certain donor countries also encourage parents or children to go to school. The Australian Government, for instance, provides supplementary food aid (such as biscuits) to children who attend the primary school in TTS. According to school management, attendance rates have increased since the supplementary food has been provided. For the last one year, we received aid [from Australia] in the form of biscuits. The biscuits were distributed each day to children. They liked them. And since we have distributed the biscuits the children are rarely absent. So, this is like a present for the children so that they will actually come to school each day. (Primary school teacher (female) in Batu Putih, TTS, NTT) The Government of Holland is another donor that urges parents to school their child by providing scholarships for children who are categorized as poor. It is hoped that the assistance will enable children who do not routinely attend school due to economic reasons to routinely attend school. The SMERU Research Institute 65 V. CONCLUSION AND RECOMMENDATIONS 5.1 Conclusion Sample region characteristics that influence demand for modern MCH and basic education services 1. It is difficult to physically access the majority of villages in NTT and isolated and remote areas in West Java. In NTT, the majority of roads have rock-hardened surfaces, are steep, windy, and slippery and muddy when it rains. Several hamlets are separated by rivers that do not have bridge crossings and so cannot be crossed in the rainy season due to high water levels. Rural transportation facilities are almost nonexistent, with the exception of motorcycle taxis, which are relatively expensive by local standards. In West Java, several villages are relatively easy to access and have adequate public transportation facilities. Some villages have rural transportation (usually minibus) available and almost all villages have many motorcycle taxis. Nevertheless, the rural transportation does not reach several villages and isolated or remote hamlets. 2. The main livelihoods of the majority of sample communities in NTT and West Java are farming and fishing. While West Java is relatively fertile, land in NTT tends to be rocky and infertile. Apart from tending cash crops like tamarind and raising livestock, farmers in NTT often rent or buy land outside the village for planting various varieties of seasonal crops. In doing so, the whole family, including pregnant women and school-aged children, usually leaves the village for several months. Particularly in coastal regions in West Java, fish shortages in fishing areas close to villages during specific seasons mean that fishermen must leave the village to go to sea with the whole family, including pregnant women and school-aged children, for a short period. 3. In the majority of study villages in NTT, basic facilities such as electricity and water are very limited or unavailable. It is difficult for village communities in NTT to obtain clean water for household and agricultural needs and schools and only villages close to subdistrict centers can access state electricity. Such conditions, compounded by poor road conditions and transportation facilities, mean that many village midwives and teachers are unwilling to live in their assigned village. In the majority of study villages in West Java, basic facilities are satisfactory, except in the coastal villages in Cirebon, which must purchase water for drinking and cooking needs. Why do some communities in Indonesia not use maternal and child health services? Supply 1. There are adequate numbers of modern MCH facilities in areas where physical access is not a problem, but in areas far from reach, these facilities are still lacking. Village midwives are the main providers of modern MCH services in all villages. In hard to reach or isolated areas in NTT, not all village midwives are willing to live in their assigned village due to the minimal level of basic facilities and/or because their family lives in another village. Consequently, the polindes can become inactive. 66 The SMERU Research Institute 2. Large working territories can mean that village midwives are unable to service all community members even if the midwife resides in the assigned village. In addition, the polindes is left unattended for long periods of time when a village midwife conducts house calls. Ideally, wide territories should have more than one village midwife. 3. All villages, in fact all hamlets, have a posyandu. Most of them are active and routinely held each month, and each is well-managed by three to five cadres. Nevertheless, attendance levels for posyandu participants (pregnant women and under-fives) are still low. To date, posyandu cadres have been central to providing MCH services. In West Java, all posyandu cadres are women, while in NTT, there are many male cadres. 4. Village midwives face their main obstacles in servicing the community when they try to reach certain groups, which are (1) those who are unaware or not particularly aware of the importance of MCH services, such as communities that still revere the customs. In NTT, this constitutes communities that still practice se'i, while in West Java, this may be communities where men do not want their wife's genitals to be seen by another person; (2) farming communities that work in fields far from the main settlement; and (3) fishing communities who go to sea far from the village. 5. Other obstacles for village midwives include the absence of transportation facilities to help them cover their large territories and isolated areas, the small number of village midwives, and irregular incomes. In NTT, village midwives are more reliant on income from the reimbursement of delivery fees from Askeskin, which in reality are not that easy to claim, while in West Java, patients are occasionally late in paying their installments for midwife services. 6. Although their numbers are declining, dukun beranak are still operating. Between one and five dukun beranak are operating in each research village/kelurahan. In West Java, their role in the delivery process is increasingly shifting from being involved in the delivery process to only becoming an assistant to the midwife and taking more of a role in caring for the birthing mother and infant. In NTT, while in general the community uses midwife services, in areas difficult for the village midwife to reach, dukun beranak are involved in prenatal care, mainly in checking and correcting the foetus's position, and in the delivery process. Demand 1. Communities choose to use a village midwife based on their knowledge that medically, midwives can be relied upon. For example, they can be trusted to assist with risky deliveries, they have comprehensive equipment and medical supplies, they can give "suntik sehat", and they can provide referral letters to the hospital. Pregnant women also feel more confident for the birth of their first child to be handled by a midwife rather than a dukun beranak. In addition, people may choose to use a village midwife as they can pay the delivery fee in installments even though the fees are relatively expensive compared to those of a dukun beranak; they are afraid that they will be fined if they do not; afraid the midwife will not be willing to check them again if they do not deliver with the assistance of the village midwife; and they obtain additional services such as a birth certificate, a gift of baby equipment, and ear piercing for baby girls. The SMERU Research Institute 67 2. Almost all children are immunized by the village midwife. However, some infants were not initially immunized usually because the parents were concerned that the infant would run a fever and would be fussy if they were immunized. Immunizations are mostly done at the posyandu. 3. Although there is good community awareness about the importance of weighing infants and under-fives and most community members rely on posyandu, some still do not attend the posyandu. Reasons for this include that (1) the child does not want to go onto the scales; (2) they believe that the scales are inaccurate; (3) the child is ill; (4) they are unmotivated as the child has been fully immunized (for children over 3 years), no supplementary food is being provided, the location is not stimulating for children or there is no play area, usually the posyandu cadre collects them to take them to the posyandu, or the road is muddy; (5) the guardian is busy working; for example, trading at the market, fishing at sea, or harvesting; (6) no one is available to take the child, for instance, because the mother is abroad working as a migrant worker and the grandmother is considered to be too old and unable to go to the posyandu; (7) the false perception that a child's weight has no relation to health; (8) the mother is embarrassed to attend the posyandu because she has many children (more than 5) and gives birth over the age of 45 years; and (9) there is flooding, meaning that the river is uncrossable. 4. Physical access limitations and isolation, economic access limitations, and belief in se'i in NTT are the main reasons why community members do not use modern MCH services for pre- and postnatal monitoring or for delivery. Isolation can be caused by great distances from modern MCH services; poor road conditions, including being difficult to pass and mountainous, having to cross a river without a bridge, or passing through forest; a lack of transportation facilities; a lack of basic facilities such as electricity, meaning that the road is dark and attracts thieves; and an unavailability of a village midwife. These factors can mean that community members rely on posyandu, pusling, or puskesmas officers who are not always available. Limited economic access is related to the high cost of delivery and transportation and can also lead to the need to work far from the main settlement. Moreover, women who are undergoing se'i cannot go out for 40 days and therefore the midwife is unable to access them. 5. Other causes for non-use of modern MCH services include that (1) the midwife is not available; (2) mothers are embarrassed or ashamed due to having many children or husbands do not want their wife's genitals to be seen by another person; (3) there is a traditional belief in the use of dukun beranak services; (4) there is trust in the expertise of the dukun beranak. 6. Service quality does not dissuade community members from using modern MCH services, but some community members are dissatisfied with midwife services. Dissatisfaction is often related to the midwife's character, ineffective medicine, minimal experience of the midwife, difficulties in reaching the midwife, and a midwife's absence from the post. 7. Some community members use neither modern MCH services nor dukun beranak during delivery as they are assisted by the husband, close family, or neighbors. This is usually as a result of the infant being delivered before the village midwife or dukun beranak arrived. 68 The SMERU Research Institute 8. Actors at the village level that support the use of modern MCH services are village officials, village midwives, posyandu cadres, religious figures, neighbors, spouse, extended family (mother or mother-in-law), and tokoh adat. Why do some Indonesians not send their children to primary or junior high school or their equivalents? Supply 1. In terms of quantity, the existence of a primary school in each village is considered to be sufficient. However, from both the quantitative and qualitative sides, the facilities for teaching and learning activities and school infrastructure in West Java are still inadequate. The situation is more dire in NTT. In West Java, each village has two to three state primary schools, while on average, villages in NTT have only one primary school, the majority of which are private religious schools. Apart from having too few classes, many classrooms are no longer suitable to be used: the plasterboard ceiling is broken and school benches are unmaintained. Several primary schools do not have a library; if there is a library, conditions are poor and the book collection is lacking. This is also the case with visual aids and sporting equipment, which are still minimal. In NTT, there are still many schools, mainly primary schools, that only have thatched roofs, woven fibre walls, and dirt floors. 2. In terms of quantity, there are too few junior high schools although the facilities for teaching and learning activities and school infrastructure are better than those in primary schools. State junior high schools are usually found in the subdistrict capital. In West Java, each subdistrict has more than three junior high schools, but in NTT, there are usually only one or two. The long distance makes junior high schools or the equivalent difficult to reach, leading to the need for schools that are closer to villages or a greater number of schools. 3. Under normal conditions, primary schools have adequate capacities. Several rural primary schools even have student shortages. Problems emerge when the majority of the community living in urban areas with more than one primary school chooses a "favorite", or popular, school. Similar problems are found in popular junior high schools as usually the community chooses to send their children to the junior high school in the subdistrict capital. 4. In order to overcome capacity limitations, school managements in several regions have issued criteria for a student selection process; for instance, setting a minimum age requirement for primary school students, grade standards for prospective junior high school students, and in NTT in particular, schools also stipulate that students must have a birth certificate from the church to ensure the background of the prospective student. In almost all regions, children with mental disabilities are refused enrollment at primary school. 5. To overcome the problems of distance and isolation, in the past two years, the government and communities in NTT have established combined primary and junior high schools in one location (SD-SMP Satu Atap) and "small primary schools", or "SD Kecil" (a remote class of the main school). The SMERU Research Institute 69 6. The main obstacle that popular schools and schools with damaged classrooms face is a lack of funds and human resources, which are needed to increase their capacity. Since the BOS program has been in place, it has been difficult for schools to ask the community to contribute to school funding due to the understanding that BOS funds are to be used to make school free. 7. Other obstacles that schools face are a lack of teaching staff, particularly teachers of specific subjects (such as mathematics and science teachers), and the low teaching quality of teaching staff. The majority of both primary school and junior high school teachers in West Java are civil servants. In NTT, the majority of teachers are nonpermanent staff, some recruited as senior high school graduates or as D2 students. 8. The main obstacles that teachers face are frequently-changing curriculums, a low parental supervision of their children's education and nutritional intake, as well as the difficulties that students have in absorbing their lessons. In addition, many parents still encourage their children to help with the family's economic activities, for example, during harvest time or when fishermen are at sea. 9. Other obstacles that teachers face are the low prosperity level of teachers and the limited available transportation to isolated areas, as almost all teachers do not reside in the village in which they teach. In addition, teachers are also burdened by administrative tasks, as the majority of primary schools do not have administrative staff. 10. In general, there are no obstacles to getting specific groups to send their children to primary school. However, this is not the case with the junior high school. Groups requiring special attention include (1) fishermen, (2) poor communities, (3) those living in isolated and remote areas, (4) communities that still revere the customs, (5) those who do not see the benefit in going to school and who do not see how going to school can benefit them in the future, (6) parents/guardians of girls, and (7) children with behavioral issues. 11. Since schools have been receiving BOS funding, community participation in the provision of school facilities has tended to decline. This is not true for isolated areas in NTT, where high awareness of the importance of going to school and the existing barriers to physical access to school has led to active community participation in the provision of education facilities and infrastructure. 12. In general, school committees at both the primary school and junior high school levels are not functioning to their full potential and generally only the committee leader has an active role. School committees are more involved in the provision of school facilities through fundraising efforts rather than in taking a role in the teaching and learning activities. Demand 1. Some parents in isolated areas in NTT are still not fully aware of the importance of sending their children to school. Some still cannot see the benefit of going to school or they cannot see that they can have a better future by going to school. These opinions are also often connected to the absence of a role model whose success is due to their education. 70 The SMERU Research Institute 2. Some communities in NTT also prioritize the customs and honor. They are willing to sell livestock for customary needs, but not for their children's school needs. A small number of parents do not send their female children to the junior high school as living unchaperoned in a boarding house may reduce the girl's bride price (belis) value. 3. Problems related to physical access and financial access are the main reasons for attrition and are why some parents do not send their children to the junior high school. Physical access or isolation are connected to great distances between home and schools; roads that are in poor condition, hilly, and muddy, and have unbridged river crossings; a lack of junior high school facilities or equivalent nearby; and a lack of transportation facilities. 4. Financial access problems are connected to the associated school costs and the cost of everyday family needs. Associated school costs include transportation costs, purchase of books, LKS, school equipment, uniforms, and snack money. Parents' inability to fulfill these high associated education expenses cause students to become embarrassed or ashamed, finally resulting in attrition. In addition, many children are forced to withdraw from school as they must help their parents earn a living by working. Financial access problems are also related to parents' inability to pay absenteeism fines that a child may have accumulated. While BOS can cover tuition fees, associated school expenses can be particularly burdensome for families. 5. Another reason for attrition from the junior high school or for not continuing to the junior high school is that the child does not want to go to school. Children may instead choose to help their parents who may be experiencing financial difficulties by working or earning money and they cannot see how going to school will afford them a better future. This may also be due to an inability to retain lessons, possibly caused by a low nutritional intake, a lack of parental supervision, or behavioral issues. 6. The majority of both primary school and junior high school students have never been absent from school for an extended period and attend school as per the regulations. Generally, if a child is absent from school, it is because of their suffering from an illness, having uncompleted homework, going home from the boarding house to pick up food for the following week (for junior high school students), or attending a customary ceremony, family matters, or a market day. 7. Economic reasons also cause students to be absent. During harvest time, students who do not directly help their parents in the fields are usually required to look after younger siblings or leave the village with their parents when the parents are working. In addition, financial limitations may mean that parents are unable to purchase a spare or replacement uniform for their child, so the child may truant if their only uniform is dirty or damaged. 8. Several reasons for students' being absent from school are related to school or teacher quality, including inadequate school facilities and infrastructure, unstimulating or boring teaching methods, the teacher's providing a poor example (for instance, the teacher often leaves class during lessons or has an inappropriate method of addressing or admonishing students), and the teacher's often being late to school. The SMERU Research Institute 71 9. Actors at the village level who actively urge parents to send their children to school are village officials, school committees, and neighbors. Village officials may issue fines to parents who do not send their children to school, explain the importance of educating one's child to parents, and make an effort to ensure that children who do not attend junior high school participate in Paket B. School committees always attend school meetings with parents even though their role is more directed at fundraising. Neighbors usually contribute by reminding parents to send their children to school although the parents may be offended. 5.2 Recommendations 1. Based on the above findings, at the very least, PNPM Generasi and PKH administrators should give attention to the following three main points: a. how both programs can respond to the main issues that frame why some people do not use modern MCH services and why some parents do not send their children to school; b. how the programs can reach specific groups, such as 1. communities living in isolated and remote areas; 2. the poor; 3. farming and fishing communities who work far away from their normal place of residence; 4. communities that usually use dukun beranak because of beliefs and traditions; 5. families with many children; 6. communities that prioritize the customs over the importance of school; 7. communities who do not see the benefit of going to school; 8. parents/guardians of girls; and 9. children with behavioral problems; and c. how the programscanharnessthe participationofinfluential actorsatthe village level. 2. Taking note of the data and information obtained in the field and the methodology used, researchers that conduct impact assessments and program evaluations need to pay attention to the following aspects. a. Researchers need to look deeper into specific topics, such as the policy of fines, various community initiatives, the role of institutions, dynamics in the relationship between officials and the community, community structure, social capital, the provision of supplementary food at posyandu and schools, locations where children absent from school congregate during school hours, and gender dimensions. b. Informants should not be limited to specific informants, depending on the needs and comprehensiveness of information obtained in the field (via snowballing method), so there are clarification and triangulation of information. c. In connection with point b above, informants at each level should not only be limited to specific informants. For example, at the subdistrict level, group interviews should be held with the subdistrict head and staff that handle or are knowledgeable about MCH services, basic education, and the village context. 72 The SMERU Research Institute Then, at the village level, hamlet heads, section heads for villagers' welfare affairs, and others should be interviewed. d. Comprehensive evaluation methods must be determined as various aid programs have entered almost all areas in NTT. This may blur the impact being observed. Besides this, researchers should also be cautious when choosing control and treatment areas as some areas that are not receiving assistance according to the program regulations are in reality already receiving or have received some form of assistance. e. A longer period of time (at least 10 days) is needed to conduct field research in each village. The SMERU Research Institute 73 LIST OF REFERENCES Tim Penyusun Pedoman Umum PKH Lintas Kementerian dan Lembaga (2007) Pedoman Umum Program Keluarga Harapan 2007 [The 2007 General Guidelines for the Household Conditional Cash Transfer]. Jakarta: Tim Penyusun Pedoman Umum PKH Lintas Kementerian dan Lembaga Departemen Dalam Negeri Republik Indonesia (2007) Buku Panduan Program Nasional Pemberdayaan Masyarakat Generasi Sehat dan Cerdas: Untuk Fasilitator Desa dan Tim Pengelola Kegiatan [Guidelines for the Community Conditional Cash Transfer: For Village Facilitators and Organizing Teams]. Jakarta: Departemen Dalam Negeri Republik Indonesia UNDP-Bappenas (2007) Laporan Pencapaian Millenium Development Goals Indonesia 2007 [Report on Achievements of Millenium Development Goals Indonesia 2007]. Jakarta: UNDP-Bappenas FURTHER READING Online Resources APN+, Policy Project, and USAID (2005) Baseline Survey of GIPA and Stigma and Discrimination in the Greater Mekong Region­Report on qualitative surveys in Lao PDR, Thailand, Vietnam, and Guangxi and Yunnan Provinces, China [online] [20 August 2007] AusAID (2003) Baseline Study Guidelines [online] [20 August 2007] Folden, Claus and Katarina Gembicka (2006) Baseline Research on Smuggling of Migrants in, from, and through Central Asia [online] [20 August 2007] Gertler, Paul (2005) The Impact of Conditional Cash Transfers on Human Development Outcomes: A Review of Evidence from PROGRESA in Mexico and Some Implications for Policy Debates in South and Southern Africa [online] [20 August 2007] Glewwe, Paul and Pedro Olinto (2004) Evaluating of the Impact of Conditional Cash Transfers on Schooling: An Experimental Analysis of Honduras' PRAF Program [online] [20 August 2007] 74 The SMERU Research Institute Rao, Vijayendra and M. Woolcock (2003) Integrating Qualitative and Quantitative Approaches in Program Evaluation [online] [31 October 2007] Rawlings, Laura B. (2004) A New Approach to Social Assistance: Latin America's Experience with Conditional Cash Transfer Programs [online] [20 August 2007] Secondary Data Data Penduduk per Usia Sekolah Kabupaten Sumedang (2007) [Data on Sumedang District's Population by School Age, (2007)] Data Potensi Kecamatan Rancakalong Semester II (2006) [Data on Rancakalong Subdistrict's Potentials for Semester II (2006)] Daftar Hadir Guru Bulan Mei Tahun 2007 SMP Negeri 1 Rancakalong (2007) [Attendance List of SMP Negeri 1 Rancakalong Teachers in May 2007 (2007)] Daftar Hadir Guru Bulan Juni Tahun 2007 SMP Negeri 1 Rancakalong (2007) [Attendance List of SMP Negeri 1 Rancakalong Teachers in June 2007 (2007)] Daftar Hadir Guru Bulan Juli Tahun 2007 SMP Negeri 1 Rancakalong (2007) [Attendance List of SMP Negeri 1 Rancakalong Teachers in July 2007 (2007)] Laporan Hasil Penimbangan Desa Rancakalong Bulan Agustus 2007 [Report on Weighting Results of Rancakalong Village in August 2007] Jumlah Rumah Tangga dan Anggota Rumah Tangga Miskin per Desa/Kelurahan, Kecamatan Rancakalong (2006) [Household and Poor Household Member Numbers in Rancakalong Subdistrict by Village/Kelurahan (2006)] Jumlah Lembaga Pendidikan Kabupaten Sumedang Tahun 2007 [The Number of Educational Institutions in Sumedang District in 2007] Data Klasifikasi Posyandu: Data Sarana dan Prasarana Posyandu Dinas Kesehatan Kabupaten Cirebon (2006) [Data on Posyandu Classification: Cirebon District's Health Office Data on Posyandu Facilities and Infrastructure in the District (2006)] Program Penuntasan Wajar Dikdas 9 Tahun di Kabupaten Cirebon [The Completion of the Nine-year Compulsory Basic Education Program in Cirebon District] Rekapitulasi APK dan APM Dinas Pendidikan Kabupaten Cirebon Tahun Ajaran 2005/2006 [Cirebon District's Education Office's GER and NER Recapitulations in the 2005/2006 Academic Year] Data Persentase Posyandu Dinas Kesehatan Kabupaten Cirebon Tahun 2006 [Cirebon District's Health Office Data on the Proportion of Posyandu in the District in 2006] The SMERU Research Institute 75 Laporan Tahunan Bidang Kesehatan Keluarga Kabupaten Cirebon Tahun 2006 [Cirebon District's 2006 Annual Report for the Family Health Sector] Kabupaten Cirebon dalam Angka Tahun 1999 [Cirebon District in Figures, 1999] Kabupaten Cirebon dalam Angka Tahun 2005-2006 [Cirebon District in Figures, 2005­2006] Jadwal Posyandu UPTD Puskesmas Gegesik, Kabupaten Cirebon (2007) [Posyandu Schedule of UPTD (Regional Technical Implementation Unit) Puskesmas Gegesik, Cirebon District (2007)] Profil Sistem Informasi Administrasi Kependudukan Kecamatan Gegesik, Kabupaten Cirebon Tahun 2006/Seksi Pelayanan Umum Kecamatan Gegesik [Demographic Administration Information System Profile of Gegesik Subdistrict, Cirebon District, 2006/General Services Section of Gegesik Subdistrict] Program Kerja Komite Sekolah SMP Negeri 1 Gegesik, Kabupaten Cirebon (2007) [Work Plan of the School Committee of SMP Negeri 1 Gegesik, Cirebon District (2007)] Program Kerja Komite Sekolah SMP Negeri 1 Gegesik, Kabupaten Cirebon Tahun 2006/2007 [Work Plan of the School Committee of SMP Negeri 1 Gegesik, Cirebon District (2006/2007)] Profil Desa Gegesik Kulon Kecamatan Gegesik, Kabupaten Cirebon Provinsi Jawa Barat Tahun 2007 [Profile of Gegesik Kulon Village, Gegesik Subdistrict, Cirebon District, West Java Province, 2007] Profil Kesehatan Kabupaten Timor Tengah Utara Tahun 2006 [Health Profile of North Central Timor District, 2006] Daftar Isian Potensi (Profil) Desa/Kelurahan Biboki Utara, TTU Tahun 2005 [Blank Form of Village Potentials (Profile) of North Biboki, TTU, 2005] Profil Pendidikan di Kecamatan Biboki Utara Tahun 2006 [Educational Profile of North Biboki Subdistrict, 2006] Insana dalam Angka 2005/Badan Pusat Statistik Kabupaten Timor Tengah Utara [Insana in Figures, 2005/Statistics North Central Timor District] Data Penduduk, Pendidik, dan Tenaga Kependidikan, serta Data Program Pendidikan Non-formal Tahun 2007 Se-Kota Kupang (2007) [Kupang City Data on Population, Educators, and Non- teaching StaffandData on Non-formalEducationProgramsin2007 (2007)] Profil Pendidikan Kota Kupang 2006/2007 [Educational Profile of Kupang City, 2006/2007] Daftar Isian Profil Kelurahan Tingkat Kelurahan Kota Kupang Tahun 2007: Peraturan Menteri Dalam Negeri RI No. 12 Tahun 2007, Tanggal 12 Maret 2007 [Blank Form of Kelurahan Profile of Kupang City, Kelurahan Level, 2007: Indonesian Minister for Home Affairs Regulation No. 12 of 2007, 12 March 2007] 76 The SMERU Research Institute Daftar Isian Profil Kelurahan Tingkat Kelurahan Kota Kupang: Surat Menteri Dalam Negeri RI No. 414.3/316/PMD, Tanggal 17 Pebruari 2003 [Blank Form of Kelurahan Profile of Kupang City, Kelurahan Level: Indonesian Minister for Home Affairs Letter No. 414.3/316/PMD, 17 February 2003] Kecamatan Alak dalam Angka 2007, Badan Pusat Statistik Kota Kupang [Alak Subdistrict in Figures, 2007, Statistics Kupang City] Kecamatan Maulaffa dalam Angka 2007, Badan Pusat Statistik Kota Kupang [Maulaffa Subdistrict in Figures, 2007, Statistics Kupang City] Regulation Peraturan Menteri Pendidikan Nasional RI No. 24 Tahun 2007 tentang Standar Sarana dan Prasarana untuk Sekolah Dasar/Madrasah Ibtidaiah (SD/MI), Sekolah Menengah Pertama/Madrasah Sanawiah (SMP, MTs), dan Sekolah Menengah Atas/Madrasah Aliah (SMA/MA) [Indonesian Minister for National Education Regulation No. 24 of 2007 on Standard Facilities and Infrastructure for Primary Schools/Islamic Primary Schools, Junior High Schools/Islamic Junior High Schools, and Senior High Schools/Islamic Senior High Schools] The SMERU Research Institute 77 APPENDICES 78 The SMERU Research Institute Appendix 1. List of Informants, FGDs, and Other Activities in Each Sample Village/Kelurahan and Subdistrict 1. Head of Subdistrict (Camat) 2. Head of Education Office at Subdistrict Level 3. Head of Puskesmas 4. Head of Junior High School (SMP) 5. School Committee of Junior High School (SMP) 6. Group of Junior High School (SMP) Teachers 7. School Observation of Junior High School (SMP) 8. Village Head 9. Community/Religious Leader 10. Head of Primary School 11. School Committee of Primary School 12. Group of Primary School Teachers 13. School Observation of Primary School 14. Midwife 15. Posyandu Cadre 16. Dukun Beranak (Traditional Birth Attendant) 17. Posyandu Observation 18. FGD of a Group of Mothers of Under-fives in Posyandu/Hamlet 1 19. FGD of a Group of Fathers of Under-fives in Posyandu/Hamlet 1 20. FGD of a Group of Mothers of Under-fives in Posyandu/Hamlet 2 21. FGD of a Group of Fathers of Under-fives in Posyandu/Hamlet 2 22. FGD of a Group of Mothers of Primary School-aged Children 23. FGD of a Group of Fathers of Primary School-aged Children 24. FGD of a Group of Mothers of Junior High School-aged Children 25. FGD of a Group of Fathers of Junior High School-aged Children The SMERU Research Institute 79 Appendix 2. Map of Sumedang District 80 The SMERU Research Institute Appendix 3. Map of Cirebon District The SMERU Research Institute 81 Appendix 4. Map of North Central Timor (TTU) District 82 The SMERU Research Institute Appendix 5. Map of South Central Timor (TTS) District The SMERU Research Institute 83 Appendix 6. Map of Kupang City 84 The SMERU Research Institute Appendix 7. Access to Sample Villages/Kelurahan in West Java and NTT Subdistrict/ Distance of Village Sample Accessibility District/City from the Subdistrict Village/Kelurahan Category Center (km) 1. Nagarawangi Easy 0 1. Rancakalong/Sumedang 2. Pamekaran Difficult 2 3. Buahdua Easy 0 2. Buahdua/Sumedang 4. Bojongloa Difficult 3 5. Sukaratu Easy 0.3 3. Darmaraja/Sumedang 6. Neglasari Difficult 2 7. Gegesik Kulon Easy <1 4. Gegesik/Cirebon 8. Jagapura Kidul Difficult 6­7 9. Susukan Easy 0 5. Susukan/Cirebon 10. Tangkil Difficult 5 6. Gunung Jati/Cirebon 11. Mertasinga Easy 6 7. Mundu/Cirebon 12. Mundu Pesisir Easy 2 13. Taunbaen Difficult 12 8. North Biboki /TTU 14. Hauteas Easy 2 15. Sekon Moderate 6 9. Insana/TTU 16. Susulaku Difficult 6 17. Oenenu Easy 4 10. East Miomaffo/TTU 18. Kuanek Difficult 15 19. Oenay Easy 6 11. Kie/TTS 20. Falas Difficult 7 21. Boentuka Easy 5 12. Batu Putih/TTS 22. Oehela Difficult 10 13. Alak/Kota Kupang 23. Fatufetto Easy 0 14. Maulaffa/Kota Kupang 24. Naikolan Easy 0 Source: Kecamatan dalam Angka 2007 [Subdistricts in Figures, 2007], data from subdistrict offices in each subdistrict, and/or field verification The SMERU Research Institute 85 Appendix 8. Distribution of Administration Areas in Sample Villages/Kelurahan in West Java and NTT Distance Number of Subdistrict/ Sample Number Number between Hamlets District/City Village/Kelurahan of RW of RT Hamlets (Dusun) (dusun) (km) 1. 1. Nagarawangi 3 9 37 1 Rancakalong/Sumedang 2. Pamekaran 3 6 21 1.5 2. 3. Buahdua 3 12 42 3­4 Buahdua/Sumedang 4. Bojongloa 4 14 32 Adjacent 3. 5. Sukaratu 3 8 26 1 Darmaraja/Sumedang 6. Neglasari 4 8 32 2 4. 7. Gegesik Kulon 4 11 39 3 to Hamlet IV Gegesik/Cirebon 8. Jagapura Kidul 4 8 29 Adjacent 5. 9. Susukan 5 n.a. 32 9 to Hamlet IV Susukan/Cirebon 10. Tangkil 5 5 23 4­5 6. Gunung Jati/Cirebon 11. Mertasinga n.a. 6 18 0 7. Mundu/Cirebon 12. Mundu Pesisir 4 8 28 0 8. 13. Taunbaen 4 7 14 5 North Biboki /TTU 14. Hauteas 4 8 16 4 9. 15. Sekon 3 6 12 0 Insana/TTU 16. Susulaku 2 2 5 0.5 10. 17. Oenenu 2 4 8 Adjacent East Miomaffo /TTU 18. Kuanek 3 3 6 2­4 11. Kie/TTS 19. Oenay 4 8 18 Dispersed 20. Falas 3 11 15 Dispersed 12. 21. Boentuka 4 8 16 Dispersed Batu Putih/TTS 22. Oehela 2 4 9 Dispersed 13. Alak/Kota Kupang 23. Fatufetto 2 7 24 Dispersed 14. Maulaffa/Kota Kupang 24. Naikolan 3 8 26 Dispersed Source: Village/kelurahan profiles from each village/kelurahan and field observation; n.a. = data not available 86 The SMERU Research Institute Appendix 9. Demographics of Sample Villages/Kelurahan in West Java and NTT Number Proportion Population Subdistrict/ Sample Popula- of House- of Men: Density District/City Village/Kelurahan tion hold Women (people/km2) Heads 1. 1. Nagarawangi 4,131 1,416 47.2 : 52.8 1,009 Rancakalong /Sumedang 2. Pamekaran 3,027 1,026 48.9 : 51.1 808 2. 3. Buahdua 3,332 998 49.6 : 50.4 895 Buahdua/Sumedang 4. Bojongloa 3,208 n.a. 51.5 : 48.5 600 3. 5. Sukaratu 2,576 812 48.1 : 51.9 1,979 Darmaraja/Sumedang 6. Neglasari 4,405 1,156 52.5 : 47.5 908 4. 7. Gegesik Kulon 5,779 1,805 51.1 : 48.9 1,445 Gegesik/Cirebon 8. Jagapura Kidul 7,411 2,248 48.2 :51.8 1,746 5. 9. Susukan 6,708 1,619 49.7 : 50.3 n.a. Susukan/Cirebon 10. Tangkil 6,906 1,780 52.0 : 48.0 3,200 6. Gunung Jati/Cirebon 11. Mertasinga 6,088 1,271 51.4 : 48.6 8,231 7. Mundu/Cirebon 12. Mundu Pesisir 6,016 1,285 50.4 : 49.6 3,785 8. 13. Taunbaen 1,432 339 50.8 : 49.2 73 North Biboki/TTU 14. Hauteas 1,739 391 50.5 : 49.5 820 9. 15. Sekon 867 223 51.1 : 48.9 n.a. Insana/TTU 16. Susulaku 943 225 50.1 : 49.9 94 10. 17. Oenenu 2,461 568 n.a. n.a. East Miomaffo/TTU 18. Kuanek 510 154 48.2 : 51.8 n.a. 11. 19. Oenay 2,354 120 n.a. n.a. Kie/TTS 20. Falas 2,038 535 54.6 : 45.4 n.a. 12. 21. Boentuka 1,644 406 51.6 : 48.4 n.a. Batu Putih/TTS 22. Oehela 912 258 49.8 : 50.2 n.a. 13. Alak/Kota Kupang 23. Fatufetto 4,661 1,037 50.0 : 50.0 n.a. 14. Maulaffa/Kota Kupang 24. Naikolan 6,912 1,411 45.5 : 54.5 8,429 Source: Village/kelurahan profiles from each village/kelurahan and Kecamatan dalam Angka 2007 [Subdistricts in Figures, 2007], (some subdistricts); n.a. = data not available The SMERU Research Institute 87 Appendix 10. Institutions in the Sample Villages/Kelurahan in West Java and NTT Subdistrict/ Sample Village/ LPMD/ Karang Farmers Group/ BPD PKK District/City Kelurahan LKMD Taruna Businesses 1. Rancakalong/ 1. Nagarawangi Active Active Available Sumedang 2. Pamekaran Active 4 farmers groups 3. Buahdua Active Active Active Active 2. Buahdua/ Active Active Active Active Livestock farmers Sumedang 4. Bojongloa group Darmaraja/ 5. Sukaratu Active Active Active Active 1 farmers group 3. Sumedang 6. Neglasari Bank desa (village 7. Gegesik bank), farmers group, Available Available Available 4. Gegesik/ Kulon lumbung desa (village Cirebon barn) 8. Jagapura Active Active Active Kidul 9. Susukan Active Active Active Active Cooperative, arisan* 5. Susukan/Cirebon 10. Tangkil 6. Gunung Jati/ Nadran (fishermen 11. Mertasinga Cirebon group) 7. Mundu/ 12. Mundu Active Active Active Active - Cirebon Pesisir 8. North Biboki / 13. Taunbaen Mudika 3 farmers groups TTU 14. Hauteas Active 15. Sekon 9. Insana/TTU 16. Susulaku 10. East Miomaffo/ 17. Oenenu Mudika TTU 18. Kuanek Available Available 19. Oenay 11. Kie/TTS 20. Falas 21. Boentuka Active 12. Batu Putih/TTS 22. Oehela Active Active Active 13. Alak/Kota Kupang 23. Fatufetto Active 14. Maulaffa/ Available 24. Naikolan Kota Kupang Source: Village/kelurahan profiles from each village/kelurahan and explanation from the village heads Note: *Arisan is a regular social gathering whose members contribute to and take turns at winning an aggregate sum of money. 88 The SMERU Research Institute Appendix 11. Availability of Modern MCH Services that are Accessible for Communities of Sample Villages/Kelurahan in West Java and NTT Locations of Puskesmas/Pustu No of Polindes/ Private Other Subdistrict/ Sample Village/ and Distance Pos- Village Village Private District/City Kelu-rahan Estimates from yandu Mid-wives Mid-wives Midwives Sample Villages/ Kelurahan Outside village, 1. Rancakalong/ 1. Nagarawangi 8 Available Available Available 1­2 km Sumedang 2. Pamekaran 5 Available Available Available Pustu available 3. Buahdua 4 Puskesmas Available Available Available 2. Buahdua/ Outside village, Sumedang 4. Bojongloa 4 Available Available Available 3 km Outside Outside Outside village, 5. Sukaratu 4 Available 3. Darmaraja/ village village 1­2 km Sumedang Outside village, 6. Neglasari 4 Available Available Available 2­5 km 7. Gegesik Outside Outside village, 5 Available Available 4. Gegesik/ Kulon village 2­5 km Cirebon 8. Jagapura Outside village, 7 Available Available Available Kidul near Outside 9. Susukan 8 Available Available 5. Susukan/ village Cirebon Outside Outside village, 10. Tangkil 6 Available Available village 3 km 6. Gunung Jati/ 11. Mertasinga 6 Puskesmas Available Available Available Cirebon 7. Mundu/ Outside village, 12. Mundu Pesisir 5 Available Available Available Cirebon l­2 km 13. Taunbaen 3 Available Unavailable Unavailable Pustu available 8. North Biboki/ Outside village, TTU 14. Hauteas 4 Available Unavailable Unavailable 1.5 km 15. Sekon 2 Available Unavailable Unavailable Outside village 9. Insana/TTU 16. Susulaku 2 Available Unavailable Unavailable Outside village 17. Oenenu 2 Available Unavailable Unavailable Available 10. East Miomaffo/ Outside Outside village, TTU 18. Kuanek 3 Available Unavailable village 13­15 km Outside village, 19. Oenay 4 Available Unavailable Unavailable 5­10 km 11. Kie/TTS Outside village, 20. Falas 3 Unavailable Unavailable Unavailable 8 km 21. Boentuka 2 Available Available Unavailable Outside village 12. Batu Putih/TTS 22. Oehela 2 Available Unavailable Unavailable Outside village, far 13. Alak/ 23. Fatufetto 4 Pustu Unavailable Unavailable Pustu available Kota Kupang 14. Maulaffa/ Outside kelurahan, 24. Naikolan 4 Pustu Available Available Kota Kupang 2­3 km Source: Village/kelurahan profiles from each village/kelurahan; explanation of informants: heads of puskesmas, midwives, and village heads; and FGD results The SMERU Research Institute 89 Appendix 12. Availability of Basic Education Facilities that can be Accessed by Sample Village/Kelurahan Communities in West Java and NTT Within the Sample Village/ Outside the Sample Kelurahan Village/Kelurahan Private Public Public Sample Primary Primary Private Primary Primary Subdistrict/ Village/Kelu- (SD) and (SD) and (SD) and Junior (SD) and District/City rahan Junior Junior High High (SMP) Junior High High (SMP) Schools (SMP) (SMP) Schools Schools Schools 1. Rancakalong/ 1. Nagarawangi 3 SD, 1 SMP 2 SMP Sumedang 2. Pamekaran 3 SD 2 SMP 3. Buahdua 3 SD 1 MTs 1 SMP 2. Buahdua/Sumedang 4. Bojongloa 2 SD 2 SMP 1 MTs 5. Sukaratu 3 SD 2 SMP, 1 MTs 3. Darmaraja/Sumedang 6. Neglasari 2 SD, 1 SMP 1 SD, 1 SMP 7. Gegesik Kulon 3 SD 1 SDIT, 2 MI 2 SMP 1 MTs 4. Gegesik/Cirebon 8. Jagapura Kidul 2 SD, 1 SMP 4 MI, 4 MTs 9. Susukan 3 SD 1 SD, 1 SMP 1 SD, 2 1 SMP 5. Susukan/Cirebon SMPN 10. Tangkil 3 SD 6 SMP, 1 MTs 6. Gunung Jati/Cirebon 11. Mertasinga 2 SD, 2 SMP 7. Mundu/Cirebon 12. Mundu Pesisir 3 SD 2 MI, 2 SMP/MTs 2 SMP 1 SMP 13. Taunbaen 2 SD, 1 SMP 1 SMP 8. North Biboki/TTU 14. Hauteas 1 SD 1 SMP 15. Sekon - 1 SD (Catholic) 2 SMP 2 SMP 9. Insana/TTU 16. Susulaku - 1 SD (Catholic) 2 SMP 2 SMP 17. Oenenu 1 SD 1 SD (Catholic) 3 SMP 1 SMP 10. East Miomaffo/TTU 18. Kuanek 1 SD (Catholic) 2 SD, 1 SMP 1 SMP 1 SD GMIT, 1 19. Oenay 1 SD Inpres SMP Kristen 1 SMP 11. Kie/TTS (Catholic) 20. Falas 3 SD, 1 SMP 1 SMP 21. Boentuka 1 SD, 1 SMP 1 SD 1 SD, 3 SMP 12. Batu Putih/TTS 22. Oehela 1 SD 1 SMP 13. Alak/Kota Kupang 23. Fatufetto 2 SD Inpres - 4 SMP 14. Maulaffa/Kota Kupang 24. Naikolan 3 SD Inpres - 4 SMP Source: Village/kelurahan profiles, FGD results, informant information, heads of education branch offices at the subdistrict level, and primary school and junior high school principals 90 The SMERU Research Institute Appendix 13. Community's Favorite MCH Service in Villages Easy to Access: Prenatal, During Delivery, and Postnatal Prenatal During Delivery Postnatal Village midwife/nearest midwife Village midwife/nearest midwife Village midwife/nearest midwife Puskesmas Dukun beranak Dukun beranak Dukun beranak Puskesmas Puskesmas Local posyandu Polindes Local posyandu Polindes Private medical doctor Polindes Nearest clinic Nearest hospital Nearest hospital Nearest hospital Convent clinic Convent clinic Source: FGD results, processed Appendix 14. Community's Favorite MCH Service in Villages Difficult to Access: Prenatal, During Delivery, and Postnatal Prenatal During Delivery Postnatal Village midwife/nearest midwife Village midwife/nearest midwife Village midwife/nearest midwife Dukun beranak Dukun beranak Dukun beranak Puskesmas Puskesmas Local posyandu Local posyandu Polindes Puskesmas Polindes Polindes Pustu Nearest hospital Source: FGD results, processed Appendix 15. Community's Favorite MCH Service in Cities: Prenatal, During Delivery, and Postnatal Prenatal During Delivery Postnatal Village midwife/nearest midwife Village midwife/nearest midwife Village midwife/nearest midwife Puskesmas Nearest hospital Dukun beranak Posyandu Dukun beranak Family Nearest hospital Puskesmas Posyandu Doctor Puskesmas Nearest clinic Hospital Dukun beranak Polindes Pustu Source: FGD results, processed The SMERU Research Institute 91 Appendix 16. Community's Favorite Place for Their Under-fives' Immunization Village Easy to Access Village Difficult to Access City Local posyandu Local posyandu Local posyandu Puskesmas Puskesmas Puskesmas Village midwife/nearest midwife Village midwife/nearest midwife Pustu Polindes Polindes Village/nearest midwife Nearest hospital Nearest hospital Nearest hospital Convent clinic Source: FGD results, processed Appendix 17. Community's Favorite Place for Weighing Their Under-fives Village Easy to Access Village Difficult to Access City Local posyandu Local posyandu Local posyandu Puskesmas Puskesmas Puskesmas Village midwife/nearest midwife Village midwife/nearest midwife Pustu Polindes NGO Village/nearest midwife Nearest health clinic Polindes Nearest hospital Pustu Source: FGD results, processed Appendix 18. Places to Obtain Nutrition Treatment according to the Community Village Easy to Access Village Difficult to Access City Local posyandu Puskesmas Local posyandu Puskesmas Local posyandu Puskesmas Village midwife/nearest midwife Village midwife/nearest midwife Pustu Doctor Local doctor Nearest hospital Nearest hospital Nearest midwife NGO Polindes Pos Gizi (Nutritional Treatment Post) NGO Pos Gizi (Nutritional Treatment Post) Nearest hospital Source: FGD results, processed 92 The SMERU Research Institute Appendix 19. Beliefs in the Customs regarding Prenatal, During- Delivery, and Postnatal Practices in West Java and NTT Prenatal - West Java THINGS THAT MUST BE AVOIDED ·Sleeping too much ·The mother sleeping on her stomach ·Taking a nap; if the mother does this, she has to take a bath. ·Putting towel/sarong around the neck (fear of baby getting strangled) ·Tying any kind of things ·Standing on the door (baby would not come out) ·Sitting on a stone ·Squatting ·Sitting with outstretched legs ·Sitting closs-legged ·Exposing the stomach ·Cleaning up ·Walking under the scorching sun ·Going out during the magrib time (right after the sun sets)/at night ·Going out after the subuh time (dawn) ·Going to the river/toilet late in the afternoon ·Hating someone/something bad ·Often getting upset ·Often cursing ·Speaking recklessly ·Annoying others ·Talking about bad things ·Ridiculing the disabled ·Killing animals (if one hated a monkey, the baby would look like one, seeing someone with a cleft lip would make the baby suffer the same thing, if one of these happens, the mother should say `tengiling'/'amit-amit'; similar to the expression `knock on wood') ·Slaughtering a chicken (baby's fingers would be incomplete) ·Eating food on a big plate ·Eating hot food (baby would be bald) ·Collecting garbage, sweeping the floor not done completely, sitting on the door ·Eating noodles ·Using needles recklessly ·Sewing (baby would be disabled) ·Working too hard ·Sewers being clogged ·Drinking sweet drinks ·Cooking rice; taking the rice without the langseng (steaming container) ·Eating fruits that are not peeled first (they have to be peeled with a knife) ·Eating food on a pincuk--a wrap from leaves, without releasing the sticks first (difficult delivery) ·Consuming ice water or chili sauce (baby would become big) ·Eating bancel fish (umbilical cord would not come out) ·Eating food directly without cutting it using a knife ·Eating `banana heart', squash, papaya ·Eating banana (baby would be overweight) ·Eating mengkudu fruit, also known as morinda citrifolia (baby would have ulcers) ·Eating pineapple ·Eating jengkol, also called ngapi nut ·Eating eggplant ·Eating shrimps (baby would become a lazybone) The SMERU Research Institute 93 ·Eating kerupuk (chips made of fish or shrimp; so that breathing is not obstructed) ·Eating crabs ·Eating meatballs ·Eating rice crust (baby would become black-skinned) ·Drinking jamu (traditional drink made of herbs) without considering the harm it may cause to the baby ·Walking over a piece of wood (baby would be breech) ·Walking over a lidi (palm leaf rib) ·Walking over the husband ·Washing the feet when doing the laundry ·Husking coconuts ·Wearing long pants ·Letting the hair hang loose, not binding it ·Cutting the hair ·Wearing jewelry when pregnancy is old ·The husband cutting something ·Having a sexual intercourse ·Smoking near a pregnant mother ·Putting food into the pocket (the baby would have big testicles) THINGS THAT ARE MUST-DOS ·If a pregnant mother takes a nap, she has to take a bath afterwards. ·Going under the bed when there is an eclipse ·During an eclipse, the mother has to be bathed by the husband in front of the house. ·Kitchen appliances have to be put on their places face up. ·Waking up and taking a bath early in the morning ·Waking up in the morning with the bottoms raised ·Doing laundry and mopping a lot ·Moving a lot ·Walking/moving a lot ·Eating a lot of liver to increase blood ·Carrying small scissors or other sharp objects ·Carrying garlic, panglay/neddle (so that evil spirits would not disturb) ·Doing good deeds ·Cleaning up the bathroom and the yard (baby would be clean and delivery would not be difficult) ·Saying `ingat-ingat' or `amit-amit' if there is something that is undesirable ·Reciting the Koran ·Praying a lot ·Cleaning up the body ·Cleaning up clogged sewers ·Eating fruits ·Drinking a lot of water ·Drinking the milk of air kapur (lime milk) ·Conducting syukuran (thanksgiving) during four months and seven months of pregnancy ·Obeying the parents ·Being careful when going somewhere on a car ·Using something as a mat for sitting ·When falling down, the mother has to slap the kain (cloth). ·When eating fruit, it must be cut into halves. ·When taking a bath, the mother must also spray the panglay. ·When sweeping the floor, the dirt must be immediately put away. ·When washing something black like a frying pan, it has to be really clean. ·The wife's wants have to be fulfilled. ·Eating pomegranates ·Eating on a small plate ·Eating yolks and fish oil when nearing delivery ·Eating chicken eggs ·Drinking jamu, milk, and turmeric broth 94 The SMERU Research Institute ·Drinking coconut milk and betel leaf broth (for easy delivery) ·Consuming coconut oil already mixed with orange ·Wearing a dress ·Using safety pins in the bra (guarding against spiritual things) ·Garbage plactic bag must be left open. ·Often getting a massage, once a month ·Saying the prayer five times a day ·Taking a bath in the afternoon so that the baby becomes freshened Source: FGD results, processed During Delivery ­ West Java THINGS THAT MUST BE AVOIDED · Wearing golden jewelry · Tying up the hair (it will cause the baby to be difficult to deliver) · Panicking · Feeling despair (the mother must be strong) · Talking too much · Crying · Eating too much · Eating chips (made of fish or shrimp) (it may cause the mother to be short of breath) · Closing the eyes; falling asleep · Clicking teeth against each other · Moving too much · Raising the hips too high · Raising the legs · Sitting with legs spread wide apart · Sitting · Sitting with legs stretched out · Going to the toilet · Running (it can cause the baby to come out) · Bearing down too hard and making noise (it is embarrassing to shout during delivery) · Bearing down before it is time · Bearing down all at once · Bearing down by forcefully contracting the neck muscles · Closing the window curtain and door · Sleeping using a pillow · Thinking about weird things · The husband being in the same room · The husband wearing pants (he must wear sarong) · The husband loafing around (`something'/spritual beings will follow) THINGS THAT ARE MUST-DOS · Opening all closed kitchen utensils · Opening all doors and windows · Preparing a small knife, a fan, and a candle on one side of the delivering mother · Wearing skirt cloth · Preparing concoctions such as panglay (made of Bengal ginger) · Husband giving encouragement and motivation to his delivering wife so that she becomes strong and tough · Praying a lot · Walking, squatting, and prostrating a lot · Drinking a lot of milk · Stroking the breasts · Applying lubricant to the bed; so that the delivery will be smooth · The husband wearing sarong, not pants The SMERU Research Institute 95 · The husband not sleeping at night · The husband blowing the wife's crown so that the baby would come out soon · Calling God's name so that the delivery will go well · Drinking the broth of mustajab leaves so that the delivery will go well · Drinking a spoonful of coconut oil so that the delivery will go well · Eating before the delivery so that the mother will have enough energy · Eating yolk of a kampong chicken egg mixed with honey · Eating kulit warak so that the mother will deliver soon · Eating cingcau (a kind of jelly) so that the mother will deliver soon · Eating brown sugar so that the delivery will not smart · Eating pepper and garlic · Eating dry-fried peanuts · Boiling water to be used for bathing the baby · Eyes being wide open · Lying back · Sleeping in a sideways position · Legs being outstretched · Knees being bent · Bearing down hard · Taking a long deep breath so that the mother can bear down hard · Saying the azan (the calling for prayers) (when the baby has been delivered) · Taking a walk when it is still 1-cm dilation · Stepping over the mother's stomach when the baby is difficult to deliver · Drinking the broth of sembung (wild heliotrope) leaves and betel broth so that the blood does not smell · Drinking lime juice so that the mother will be healthy · Drinking sprite, sweet tea, and fingerroot broth · Drinking turmeric broth Source: FGD results, processed Postnatal ­ West Java THINGS THAT MUST BE AVOIDED · Defecating in a squatting position (the mother has to stand up) · The mother doing laundry before the 7-day recuperation is over because the suture is not dry yet · If giving birth with a paraji (traditional birth attendant), for 40 days, the mother must not do laundry or do hard labor · Sitting with legs spread wide apart · Lifting heavy objects; doing hard labor · Moving too much · Eating oily food · Eating a lot of vegetables · Eating pineapples · Eating tamarind because it is not good for the mother's milk · Eating noodles · Eating squash; so that the mother's stomach will not become big · Having dinner for 40 days · Eating yellow rice · Eating very warm foods · Eating spicy foods · Drinking hot water · Eating salted fish and eggs · Eating jengkol (ngapi nut) and petai (parkia speciosa) · Eating long beans · Eating green banana because the stomach is not totally cured yet · Eating zallaca palm and jackfruit · Consuming santan (coconut milk) · Not being cautious with the foods that the mother eats 96 The SMERU Research Institute · Drinking iced drinks · Shampooing the mother's hair; not until 40 days when she is clean from blood · Taking a bath for 3­4 days after childbirth; only being rubbed with clean wet cloth · Before 40 days, the mother must not take a nap (according to the paraji and parents) · Putting on a makeup; so that the husband becomes unattracted · Taking a nap because this can cause the blood to flow up to the eyes · Leaving the baby unattended · Breastfeeding whilst lying down · Standing up too long · Sitting on a broken chair because it might cause the suture to bleed again · Cutting the hair · Tying up the fence (the baby's arms might be overstretched) · Hurting animals · Turning on machinery (it can cause the baby to quiver) THINGS THAT ARE MUST-DOS · Saying the azan to the baby so that it will grow up to be a good child · Burying the placenta properly · The husband must not have sexual intercourse with or be near the wife for 50 days · The husband must carry on doing the usual daily activities until the umbilical cord comes off. · The husband doing the laundry at the river (to clean the blood from childbirth) · Working a lot · Taking a lot of rest · The mother being accompanied all the time in the morning and late in the afternoon for 40 days · Rubbing the belly button in a circular motion so that the blood would come out immediately · Wearing bengkung/stagen (sash) for 40 days · Using a contraceptive after 40 days · Getting a massage · Sitting on warm ash · Sitting with legs stretched out · Being rubbed with beras kencur (a mixture of pounded rice--beras--and kencur--aromatic ginger-- root) (for both mother and baby) · Baby being sunbathed in the morning · Breastfeeding · Taking a walk in the morning so that everything goes well and having the mother's health checked · Taking a bath by showering the mother's head in the morning and late in the afternoon · The husband must do the mapas (the husband tastes all the food that the wife eats); he has to do this until the umbilical cord comes off. · For 40 days after the childbirth, the mother may not eat after magrib (sunset) · Eating tamarind because this can make the mother's uterus to be in a good condition again · Eating salted fish so that the mother becomes thirsty and therefore drinks a lot; this way, there will be plenty of mother's milk · Eating liver, chicken, spinach, water spinach, yam bean, and papaya · Eating kelor (merunggai) leaves · Eating nutritious food (rice, vegetables, fruits, milk, tempe, fish, chicken) · Eating fish to make the mother's body healthy and fit · Eating peanuts and corn so that the mother's milk is plenty · Eating yellow rice · Eating katuk (a kind of bush yielding edible leaves and berries) soup, jaat (winged bean) seed, papaya leaves, tip of waluh (squash), and cassava leaves so that the mother's milk is plenty · Drinking sembung leaf broth; it shrinks the uterus · Drinking brown sugar broth · Drinking sweet tea/drinks · Having ginger drinks so that the mother's milk is warm · Drinking jamu for 40 days since childbirth · Taking medicine · Drinking the broth of betel and sembung leaves so that the uterus will shrink immediately · Drinking milk Source: FGD results, processed The SMERU Research Institute 97 Prenatal ­ NTT THINGS THAT MUST BE AVOIDED · Having sex, not for the first three months · Moving too much when pregnancy has reached seven months old · Sitting on the door, causing difficult delivery · Squatting, sleeping in a supine position (causing difficult delivery) · Sitting cross-legged (causing the feet to swell) · Cutting the hair · Traveling long distances on a public transport (there may happen unwanted things) · Walking at night; the mother may get a `bad wind' (something like catching a cold) · Walking in broad daylight (which is scorching) · Eating food hard to chew (causing difficult delivery) · Eating octopus, squid (umbilical cord would be sticky) · Eating fish; the baby would be disabled. · Eating `banana heart', squash, papaya · Eating banana (the baby would be overweight.) · Taking a bath at night · Killing animals · Weaving · Hanging towel on the neck (fear that the umbilical cord would strangle the baby) · Ridiculing other people, getting angry (causing difficult delivery) · Sewing on bed (baby's ears would be missing) · Drinking ice water · Drinking · Taking any kind of medicine (that is unknown of its safety for pregnant mothers) · Mocking a person with a cleft lip (baby would be born similar) · Slaughtering an animal (baby would be disabled) · Often going on a ride on vehicles · Carrying a knife · Sitting with the back facing other people · Walking alone · Working too hard (during the first four months of pregnancy) · Eating fried corn (baby would be difficult to deliver) · Eating chili (baby would have swollen eyes and be bald) · Eating laok mone (a type of cassava) · Eating sugar cane (causing bleeding during pregnancy) · Eating shrimps (causing difficult delivery) · Taking a bath at night (there would emerge twin babies from the water) · Wearing jewelry (baby would be strangled by its umbilical cord) · Swearing/hitting people · Drinking sweet drinks · Riding on a motorcycle · Climbing trees · Putting sirih pinang (a dish containing betel leaves, nuts, and lime) on top of the head · Eating too much nutritious food, except fish · Sleeping in a supine position (baby would be twins and if wanting to change positions, mother has to get up first.) · Carrying a child · Not taking the prescribed medicine THINGS THAT ARE MUST-DOS · During 7­8 months of pregnancy, carrying wood, drawing water from well, moving a lot · Taking a lot of rest · Often taking a walk 98 The SMERU Research Institute · Sitting carefully (fear of falling and causing miscarriage) · Eating fruits · Eating porridge · Eating fish · Taking the key to the cupboard along when travelling · Put a nail on the hair when traveling at night · Taking a morning walk and mopping the floor · Getting up first when changing positions during sleep so that the baby would not be breech · Carrying scissors, nails, and comb when traveling at night to scare off the ghosts · Doing light chores · Eating merunggai leaves after seven months of pregnancy so that the umbilical cord would come out easily · Eating eggs, meat, vegetables, and milk · Carrying nails, scissors, and knife to scare off the ghosts · Drinking coconut milk so that the baby would be clean · Consuming little coconut oil when nearing delivery · Drinking a shot of sofi kepala (a liquor) once a week · Repairing the traditional clan house · Taking a bath diligently · Asking for and giving forgiveness · Immediately burying the dead · Saying the prayers during seven months of pregnancy · After 6­7 months of pregnancy, doing hard work such as carrying wood, plowing the garden · The husband collecting wood for making smoke · Getting massages from the dukun beranak Source: FGD results, processed During Delivery ­ NTT THINGS THAT MUST BE AVOIDED · Burning a candle · Wearing jewelry · Wearing a hairpin; so that the delivery will go well · Tying up the hair · Kneeling · Sitting down while urinating; in fear that the mother's waters will break · Sitting with legs spread wide apart · The husband cheating on the wife; the baby will be the victim and the wife will have a difficult delivery · The husband wearing a ring · Bearing down (muku) forcedly; it can make the mother exhausted. · The husband wearing a belt or blanket · Moving; so that the baby does not move either · Rolling over back and forth on the bed · Eating papaya · The eyes being blindfolded; it can cause the baby's eyes to be blind · Looking upwards · Lifting the bottoms; it can cause more perineal tears · Taking a breath; the baby may be sucked back in · Shouting; the mother will get tired up fast or be unable to bear down · Sleeping using a pillow · Eating tamarind · Eating pork · Drinking cold water · Taking a bath with cold water The SMERU Research Institute 99 THINGS THAT ARE MUST-DOS · Burning a candle on an ancestor's grave so that if there is a problem with the family, the delivery can be an easy one · Having a discussion together with families from the mother's and father's sides about the belis that has not been fully paid yet · Scattering about rice all over the traditional clan house · Taking off jewelry · Taking off the hair bun and letting the hair hang loose · The husband taking off his belt and pants · Taking a walk quite often · Reserving energy for the delivery · Walking slowly · Drinking water that has been blessed if the delivery is too painful · Drinking sweetened water · Drinking jamu specially prepared for pregnant mothers · Drinking a mixture of honey and eggs · Taking a spoonful of coconut oil so that the delivery will be `smooth' · Only the midwife and the dukun beranak being in the delivery room · Apologizing directly to the person for the mistake that has been done · The family sprays water with the mouth to the delivering mother's head · Chewing alia and blowing at the mother's crown so that the umbilical cord can come out smoothly · Eating fried pumpkin seeds so that the baby can be delivered easily · Only wearing skirt cloth when delivering · Rolling the mother's body over so that the baby stands still/does not incline · Praying with the help of the dukun beranak · Lifting the head · Rubbing the stomach with sand and candlenut · Tying up a rope and holding it tight · If the baby is difficult to deliver, the husband has to step over the wife's body 3 times. · Holding breath or inhaling slowly · Being pressed at the back or from behind · Being in the sleeping or kneeling delivering position · Holding the husband's shoulder · Bearing down (muku) as if urinating · Sitting with legs spread wide apart · Consuming bose (pounded corn), eggs, vegetables; milk, and fruits · Eating porridge · Eating food without salt · Only taking a bath by being rubbed with clean wet cloth so that the baby would be delivered soon Source: FGD results, processed Postnatal ­ NTT THINGS THAT MUST BE AVOIDED · Getting off the bed; not until a week · Getting out of the house; not until 40 days (60 days in some places); the mother has to cover her body if she urgently needs to get out · The mother and baby must not be held, especially, by the father (husband) · Taking a bath with cold water because it can cause the white blood to flow up to the head · Washing the hair; not until 40 days · Doing laundry and cooking; not until 3 months · Moving · Doing manual labor · Consuming salt; not until 40 days · Eating corn; it can cause stomachache. · Eating oily food and pork 100 The SMERU Research Institute · Eating fish; it can cause the mother's milk to smell rancid · Eating papaya leaves, salt, and hard foods · Eating chili because the uterus has not healed yet · Eating meat; not until 4 days · Drinking cold water and eating cold food; to keep the mother's milk coming out smoothly · Getting angry because it can cause the white blood to flow up to the head · Sewing, and watching TV; not for 1­2 weeks; the white blood may flow up · Lifting heavy objects THINGS THAT ARE MUST-DOS · The first sleep having to be in a face down position · Using candlenut, and then applying tatobi (hot water compress) · Applying compress with a mixture of daun besi (literally iron leaves) and tamarind leaves · Taking a hot bath for 5­9 days · Undergoing se'i (the mother and the baby stay in a round house or a traditional clan house and then are `roasted' in order that the mother's wounds can dry quickly; the charcoal is placed beneath the bed) for 40 days · The mother being bathed/rubbed with hot water for 3 months · The stomach being tied up with a stagen so that it does not become big · Getting off the bed after 4 days · If getting out of the house, the mother has to be covered in cloth (if not, the white blood will flow up to the head) · Closing all doors and windows · Burning incense · Eating hot porridge · Eating corn and nuts so that the mother's milk will come out smoothly · Eating nuts · Eating vegetables, meat, and eggs · Eating hot foods · Drinking a lot of drinking water · Drinking traditional kampong concoction · Keeping the umbilical cord for 3 days by wrapping it first, putting it in an earthenware jug, and hanging it on a tree · The baby being breastfed · Holding a thanksgiving for the baby after 40 days and summoning a dukun beranak Source: FGD results, processed The SMERU Research Institute 101 Appendix 20. Criteria of Good Schools and Teachers according to the Community Province Good School Good Teacher West Java Intelligence level of graduates Relatively high level of education degree Varied school activities Teachers continue their studies Good quality of educators/teachers High discipline, punctual High level of education degree for the Good conduct teachers (D3­S1) Good teaching methodology Teachers' high discipline Giving much attention to students Good school infrastructure Teaching lessons in detail, not only Complete facilities such as computers, writing on whiteboard and leave sport equipment, praying facilities students to learn on their own Learning takes place in accordance Having authority in front of students, and with schedule being strict, but not being feared as Good parent-teacher communication described well by the Sundanese Good teaching methodology proverb "harus leuleus jeujeur liat tali" Disciplined students Having a sense of humor Disciplined teachers Having broad horizons High level of teachers' attention for students Able to bring good change to students' behavior NTT Guaranteed education quality Friendly Active teachers and students Nice to parents Punctual in starting school hours Good teaching techniques, not Punctual in starting lessons necessarily bachelor's degree holders Students are serious in learning Lesssons given suit the students ability Students are polite When absent, substitute teachers give Teachers give lessons in the morning, the correct lessons afternoon and evening Teachers are active, giving lessons every Teachers do not hit students day Teachers give homework. Punctual, not wasting time Students are high achievers. Winning contests Complete book collections Graduates are admitted in the next education level Source: FGD results, processed 102 The SMERU Research Institute