Voices of the Poor - World Banksiteresources.worldbank.org/INTINDONESIA/Resources/Publication/... · Voices of the Poor is based upon fi eld work done by a team consisting of Nyoman

INDOPOVNilanjana Mukherjee

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

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Bank Dunia | The World Bank

East Asia and Pacifi c Region

Voices of the Poor:Making Services Work for the Poor in IndonesiaA Qualitative Consultation with the Poor at Eight Sites

Nilanjana Mukherjee

Acknowledgements

Voices of the Poor is based upon fi eld work done by a team consisting of Nyoman Oka and Ratna Indrawati

Josodipoero, Co-fi eld team leaders, Wiji J. Santoso, Idul Fitriatun, Ketut Suarken, and Nur Khamid (East Java Team),

Purnama Sidi, Laksmini Sita, Herry Septiadi, and Ririn Fajri (West Java Team), Husnuzzoni, Khusairi, Nazmi Rahkman,

and Indraningsih (South Kalimantan Team), Titik Soeprijati, Irwan, Mochamad Rifai, and Ariati (West Nusa Tenggara

Team).

Field work and analysis for Voices of the Poor was supported by the Indonesia Poverty Analysis Program (INDOPOV),

a partnership program of the World Bank Indonesia led by Jehan Arulpragasam. The report is a qualitative study

intended to supplement the quantitative analysis “Making Services Work for the Poor in Indonesia.”

This work benefi ted from advice, discussion, and critique from members of the INDOPOV team, particularly Menno

Pradhan, Vicente Paqueo, Peter Heywood, and Ellen Tan. Suzanne Charles and Ellen Tan provided valuable editing

support. Claudia Surjadjaja provided health service assessment tools and briefi ng to the researchers. Consultations

with the poor were undertaken by the researchers drawn from several NGOs and academic institutions in

Indonesia.

Grateful thanks are due to the women and men consulted in the Java, Kalimantan, and West Nusa Tenggara

communities, who shared their assessments, experiences, insights, and knowledge to provide a human face and

voice to this study – which we hope will be heard by policy makers.

The author deeply appreciates the support of the management of the World Bank’s Water and Sanitation Program

(WSP), which made it possible for her to undertake this work. Specifi cally, thanks are due to Richard Pollard, the

Regional Team Leader for WSP - East Asia and Pacifi c, and Ede Jorge Ijjasz-Vasquez, the global Program Manager.

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

vMaking Services Work for the Poor in Indonesia

A Qualitative Consultation with the Poor at Eight Sites

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Table of Contents

ACKNOWLEDGEMENTS iv

TABLE OF CONTENTS v

LIST OF BOXES, FIGURES, & TABLES vi

GLOSSARY viii

EXECUTIVE SUMMARY x

1. POVERTY CHARACTERISTICS AND LOCAL INSTITUTIONS AT STUDY SITES 11. 1. Sample, Sites, Research Tools 11. 2. Identifying And Engaging With The Poor 21. 3. Local Well Being And Poverty Profi les 2

2. EDUCATION SERVICES USED BY THE POOR 42. 1. Primary Schools: Not Really Free – Despite Government Provisions 42. 2. Secondary School Education Services 62. 3. Quality Of Services - Providers’ Views 82. 4. Independent Observation Results And Conclusions 9

3. HEALTH CARE: PRENATAL, CHILDBIRTH, AND CHILD HEALTH SERVICES 143. 1. Prenatal Services: Preferences Vary With Geography 143. 2. Childbirth Assistance Services: Tba Still Reigns Supreme 163. 3. Curative Services For Young Children (< 5 Years): Public Services Are The Preferred Choice 173. 4. Quality Of Health Services Being Delivered To The Poor 183. 5. Independent Observation Results And Conclusions 21

4. “CLEAN” WATER SERVICES USED BY THE POOR 254. 1. Poor Lack Reasonable Access To Potable Water 254. 2. Water Use And Health Hazards 264. 3. The Poorest Pay The Highest Price For Water 274. 4. Observation Results: “Clean” Water Services 294. 5. Quality Of Services: Views Of The Poor 30

5. SANITATION FACILITIES USED BY THE POOR 315. 1. Observation Results: Sanitation Services 335. 2. Quality Of Services: Various Views 34

6. POOR HAVE LITTLE CLIENT POWER—BUT THEY WANT IT 356. 1. Lack Of Information-“We Don’t Know” 366. 2. “Who Will Hear Us?” 386. 3. Poor Treatment By Pro-poor Service Providers And Offi cials 396. 4. No Voice In Community Decisions And Service Provision 396. 5. Problems With The Participatory Process-“We Are Stepchildren” 40

7. RECOMMENDATIONS FOR POLICY AND STRATEGY 427. 1. For Basic Services In General 427. 2. For Health Services 437. 3. For Education Services 447. 4. For Clean Water And Sanitation Services 45

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List of Boxes

Box 1. No explanation of fees 6

Box 2. Married at 13, childbirth at 14 –the only option after primary school 7

Box 3. No clean water equals no schoolteachers and health workers 10

Box 4. 92 Enrolled but 29 Present 10

Box 5. Pregnancy danger signs unrecognized 17

Box 6. Repeated premature births, No ANC check ups 22

Box 7. No longer possessed by the devil 23

Box 8. Four days too late … 23

Box 9. How to feed my child when breast milk fails? 24

Box 10. Diarrheal death of an infant close to services in a mega city 25

Box 11. The poor pay 30 times PDAM tariff for water – but don’t realize it 27

Box 12. Held ransom by monopolistic water service 30

Box 13. “They give us no choice….” 36

Box 14. “Because i am poor, and therefore also stupid ” 38

Box 15. Kartu sehat users need patience and forbearance 39

List of FiguresFigure 1. Proportion of votes for choice of provider for primary education services 6

Figure 2. Proportion of votes for choice of provider for ANC services 15

Figure 3. Proportion of votes for choice of water services used 26

Figure 4. Proportion of votes for choice of sanitation facility used 32

List of TablesTable 1. Study sites 1

Table 2. Secondary school observations at diff erent sites 13

Table 3. Costs of clean water services and water use by the poor at 8 study sites 28

List of Annex Tables

Table 2.1. Paminggir - Remote, Forestry-dependent Rural Community, South Kalimantan 5

Table 2.2. Bajo Pulau - Island Fishing Community , West Nusa Tenggara 5

Table 2.3. Alas Kokon - Rural, Dryland Farming Community, Madura, East Java 6

Table 2.4. Kertajaya – Irrigated Rice-Farming Rural Community, West Java 7

Table 2.5. Antasari - Urban Kelurahan, South Kalimantan 8

Table 2.6. Jatibaru - Urban Poor Kelurahan on the Outskirts of Bima, West Nusa Tenggara 9

Table 2.7. Simokerto - Urban Low-Income Neighborhood and Squatters’ Settlement, Surabaya, East

Java

10

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Table 2.8. Soklat - Urban Poor Kelurahan in Subang, West Java 11

Table 3.1. Choice and Costs of Primary Education Services Reported by the Poor at 8 Sites 12

Table 3.2. Costs of secondary school education reported by the poor at 8 study sites 15

Table 3.3. Choice and Costs of ANC Services Used by the Poor at 8 Study Sites 19

Table 3.4. Cost of Childbirth Assistance Services Used by the Poor at 8 Study Sites 22

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

under Five

26

List of Annex Figures

Figure 3.1 Benefi t and value perceptions for primary education services 13

Figure 3.2 Satisfaction Ratings for Primary Education Providers 14

Figure 3.3 Proportion of votes for provider of secondary school education services 16

Figure 3.4 Benefi t and value perceptions for secondary school education services 17

Figure 3.5 Satisfaction ratings for secondary school education providers 18

Figure 3.6 Benefi t and Value Perceptions for ANC Service Providers 20

Figure 3.7 Proportion of votes for choice of provider for Childbirth Assistance Services 21

Figure 3.8 Satisfaction Ratings for Childbirth Assistance Providers 23

Figure 3.9 Benefi t and Value Perceptions for Childbirth Assistance Providers 24

Figure 3.10 Proportion of votes for provider of Infant Health Care Services (2M – 5Y) 25

Figure 3.11 Proportion of votes for provider of Infant Health Care Services (0 - 2M) 25

Figure 3.12 Benefi t and Value Perceptions for Curative Services for Infants (0-2 months) 27

Figure 3.13 Satisfaction Ratings for Curative Care Providers for Infants (0-2 months) 28

Figure 3.14 Benefi t and Value Perceptions for Water Supply Option Used 29

Figure 3.15 Satisfaction ratings for water supply options 30

Figure 3.16 Benefi t and value perceptions for sanitation facilities 31

Figure 3.17 Satisfaction ratings for sanitation facilities 32

viiiMaking Services Work for the Poor in IndonesiaA Qualitative Consultation with the Poor at Eight Sites

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Glossary

ANC Antenatal Care

Arisan Saving & Credit Group

bidan desa Trained Village Midwife

BKKBN (Badan Koordinasi Keluarga

Berencana Nasional)

National Family Planning Coordinating Board

BOS (Biaya Operasional Sekolah) School Operation Costs

BPS (Badan Pusat Statistik) Central Bureau of Statistics

Dukun Local faith healer

Dusun Hamlet

GDS Governance and Decentralization Survey

GOI Government of Indonesia

Imunisasi TT (Tetanus Toxoid) TT (Tetanus Toxoid) immunization

Inpres Desa Tertinggal Presidential program for disadvantaged villages

Kangkung Leafy vegetable

Kantor Kelurahan Political District Offi ce

Kapuk Silk Cotton

Kartu Sehat Health Card

Kec./ Kecamatan Sub-district

Kelurahan Sections of the village/Urban district admistration unit

Kelurahan /Kantor Desa Political District Offi ce administered by Lurah (Village Chief )

Kepala Desa Village Chief

Kepala Dusun Hamlet Chief

Ketua RT Neighborhood Community Head

Madrasah Religious School, privately managed

Madrasah Ibtidaiyah Community-managed Islamic Schools (grades 1-6)

Madrasah Tsanawiyah Religious school, run by government (Department of Religious Aff airs), grades 6

– 8)

Mantri Paramedic

Menengah Middle/Suffi cient

MOE Ministry of Education

NGO Non Governmental Organization

PDAM (Perusahaan Daerah Air

Minum)

Regional Drinking Water Company

Pesantren Other Islamic Schools

PKK Women’s Family Welfare Program

PLN State Electricity Corporation

Polindes (Poliklinik Desa) Village Birthing Clinic

POSYANDU (Pos Pelayanan Terpadu) Integrated Services Post

Puskesmas Primary Health Centre/ Sub-district Public Health Centre

Pustu (Puskesmas pembantu) Sub-primary Health Centre (outreach facility)

Raskin (Beras Miskin) Cheap Rice

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SANIMAS Community Sanitation Project piloted in 7 Indonesian cities during 2001-2003,

promoting community-based sanitation solutions for the urban poor

SD (Sekolah Dasar) Primary School (grades 1 – 6)

SDN (Sekolah Dasar Negeri) Government – run Primary School (grades 1 – 6)

SLTP (Sekolah Lanjutan Tingkat

Pertama)/ SMP (Sekolah Menengah

Pertama)

Junior High School or Secondary School, generally grades 7-9

SLTP Negeri/ SMP Negeri Government – run Junior High School

SSIP Small Scale Independent Water Providers

TBA Traditional Birth Attendant (Sando, Dukun Beranak/ Dukun Berobat, Dukun/Bidan

Kampung, Paraji)

UKS (Unit Kesehatan Sekolah) School Health Education Unit

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

xMaking Services Work for the Poor in IndonesiaA Qualitative Consultation with the Poor at Eight Sites

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Executive Summary

In January 2001, Indonesia decentralized the delivery of most government services to the district level. The center of

gravity for innovation has thus shifted to the districts, where local governments now have signifi cant autonomy to

promote change, both positive and negative. In a country of about 2201 million people and 4402 districts and cities,

this shift has created tremendous potential for innovative local approaches for public sector service delivery.

The World Bank’s Making Services Work for the Poor in Indonesia initiative aims to provide analytical support for

the Indonesian Government’s eff orts to improve access to and quality of basic services for the poor in the wake of

decentralization. Its objectives are to summarize the state of basic service delivery for the poor, identify and analyze

key factors that have an impact on current outcomes, and propose an analytical framework and practical steps for

improving pro-poor service provision.3

None of the fairly extensive literature on decentralization has yet included an analysis of how the poor view the

delivery of public services. This report attempts to fi ll this gap. It tries to understand what constraints the poor

face, and the rationale for choices made by the rural and urban poor with respect to basic health, education, water

supply and sanitation services that they need. The report also describes policy recommendations to improve service

delivery for the poor on the basis of this analysis, and suggestions from the poor and service providers that could

help improve accountability and strengthen relationships among clients, service providers, and policy makers.

This study focused on eight types of key services:4

• antenatal services

• childbirth assistance

• curative services for 0 to 2 month old infants

• curative services for >2 months to 5 year old children

• primary schooling

• transition to secondary schooling

• clean water services

• sanitation facilities (excreta disposal)

These services are important elements in reaching the Millennium Development Goals. High malnutrition, maternal

and infant mortality, and low education can be directly traced back to failings in these services.

1 National Bureau of Statistics BPS, “Proyeksi Penduduk Indonesia, 2000-2005”, 2005

2 Ministry of Home Aff airs

3 For the full report, see the World Bank website, www.worldbank.or.id

4 For the purposes of this report, curative services have been combined. For specifi c results of 0 to 2 months and > 2 months to 5 years.

Please see Annex.

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It is hoped that this synthesis, which pulls together commonalities and diff erences among eight localities, will be

useful to donors and government in Indonesia, as well as other countries interested in practical ideas for improving

government service delivery.

By participating in the delivery of services and pressuring policy makers and service providers, the poor have

the potential to improve the quality of services they receive. The study explored to what extent the poor do this

and whether they deem their eff orts to be eff ective. The study also sought their views on how they can draw

policymakers’ attention towards the aspirations of the poor and how to improve the accountability of the service

providers to serve poor consumers.

Generally, the policy response in Indonesia to lack of utilization of basic services by the poor, or disappointing

service outcomes, has been to use targeted price subsidies for public service provision, such as the health card and

scholarships programs. These policies presume that the public sector is the most effi cient way to deliver services to

the poor and that the poor do not use them when the fees are too high. This study was designed to take a fresh look

at this hypothesis, which has been driving policy in Indonesia, and to generate suggestions for alternative policies

that are more directly related to the constraints the poor face.

The following fi ndings represent the voices of the poor from eight selected locations in Indonesia. No claim is made

about their being completely representative of the country’s poor.

A number of key messages reverberate throughout the consultations:

1. Perceptions of the poor on service quality were often at variance with independent professional views on

quality.

• The poor perceived traditional birth attendants (TBAs) to be providing better quality service for childbirth

assistance than trained nurse midwives.

• Well water is perceived as clean, whereas river water is not. While the latter is mostly correct, the fi rst is often not.

2. The primary constraint to increasing the number of births assisted by trained service providers appears to be lack

of demand rather than lack of access. The poor do not demand trained midwives’ services because midwives

charge much more and serve their clients for much shorter periods than the TBAs do. Many poor clients were

not fully aware of the additional benefi ts of professionally assisted births. Those who were aware were not certain

the additional benefi ts are worth the high extra cost.

3. Programs for the poor, such as the health card, are highly valued, but researchers found that information about

policies for the poor is typically not available. Often, the public service provider or government offi cial was the sole

source of information about pro-poor services. Often these elites failed to give the poor complete information,

and sometimes they even misused their power, preventing the poor from accessing these services.

xiiMaking Services Work for the Poor in IndonesiaA Qualitative Consultation with the Poor at Eight Sites

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4. Community elite—service providers and government offi cials— seldom listened to the poor when the poor

were stating their needs, their concerns, or ideas they have for improvements to service. The poor see themselves

as “stepchildren”; the elites consider the poor as “stupid” and do not want to interact with the poor or provide

them with information. The only way input from the poor is valued is when it is mediated through outside

partners.

5. Non-fee primary school expenses (such as uniforms, books, etc.) are a substantial burden for the poor. The recent

policy to abolish tuition fees for the poor does not address these signifi cant non-fee expenses.

6. Public perceptions about the poor being unable to aff ord quality water and sanitation services are not correct.

The poor in urban areas were buying water from private vendors at 15 to 30 times the tariff s of the district

drinking water companies (Perusahaan Daerah Air Minum, PDAM). While they could aff ord to buy water from

PDAMs at the PDAM tariff rates, they fail to obtain connections due to lack of tenure of lease or land ownership

and the high one-time cash costs of connections. Most of the urban poor could aff ord to build low-cost latrines,

but again lack of land ownership or tenure of residence stands in the way. Also, most are not aware of low-cost

latrine options, both in rural and urban areas.

7. On islands, the poor have little access to clean water, often because of the monopolistic manipulation of the

system by water vendors. This was also true in an urban slum.

8. There is a big diff erence in quality between urban providers serving slum areas and rural providers serving poor

areas. The latter are of much worse quality.

9. Particularly in rural areas, many children enrolled in school do not attend regularly. Their teachers are often

absent. High enrollment rates fail to capture non-attendance.

10. Teacher absenteeism in rural schools and the unavailability of paramedics in rural health outposts (Pustus) were

sometimes tied to the lack of basic infrastructure facilities such as water supply and sanitation facilities in rural

schools and health posts. Teachers were not willing to work in such conditions (although they were willing to be

paid).

11. When there is no secondary school in the village, such as seen in Madura, girls were married off and get pregnant

immediately after primary schooling. When there is a chance of attending junior high, such young marriages

do not occur as frequently. This emphasizes the need to improve girls’ access to junior high school for reasons

beyond educational attainment.

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1. Poverty Characteristics and Local Institutions at Study Sites

1. 1. Sample, Sites, Research Tools

Eight localities were chosen based on BKKBN poverty criteria, inclusion in the Governance and Decentralization

Survey, Badan Pusat Statistik’s poverty maps and geography/locality. Communities chosen, both rural and urban,

had high poverty rates (30 to 80 percent). Social mapping was further used at each site to identify the poorest

neighborhoods for consultation. Half of the sites were chosen on Java, which houses the largest absolute number

of the country’s poor. Two other sites, West Nusa Tenggara and Kalimantan, were included to refl ect conditions

outside Java. The 2003 GDS results had shown high satisfaction rates with public services and popular perceptions

of improved services after decentralization. The quantitative GDS results neither explained why ratings were high,

nor whether the views of the poor diff ered from that of the non-poor. Poor people’s views about services in this

study were far less positive than the GDS results, possibly refl ecting the experience of the poorest segments.

Criteria for selection of rural sites included principal livelihoods (irrigated rice-growing farmers in West Java, an

island fi shing community in West Nusa Tenggara, a forestry-dependent upland agricultural community in South

Kalimantan, and a dry land agricultural community in Madura (see Table 1).

Table 1. Study Sites

JAVA OFF-JAVA

Rural Urban Rural Urban

Irrigated agriculture-based

livelihoods

Desa Kertajaya, District

Subang, West Java

Mega city slum

community

Kelurahan Simokerto,

Kecamatan Simokerto,

District Surabaya, East Java

Forestry and upland

agriculture livelihoods

Desa Paminggir,

Kecamatan Danau

Panggang, District Hulu

Sungai Utara, South

Kalimantan

Small town community

Kelurahan Antasari,

Kecamatan Amuntai

Tenggah, South

Kalimantan

Dry land agricultural

livelihoods

Desa Alaskokon,

Kecamatan Modung,

District Bangkalan,

Madura

Urban poor community

Kelurahan Soklat,

Kecamatan/Kota Subang,

West Java

Coastal fi shing

community

Desa Bajopulau, District

Sape, West Nusa Tenggara

Small town community

Kelurahan Jatibaru, Bima

City, West Nusa Tenggara

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Research methods included the use of participatory analysis tools and focus group discussions with poor men and

women, and in-depth interviews with individuals selected for case studies. A total of 450 people were consulted.

The views of four subdistrict health center doctors, six village midwives (bidan desa), two paramedics, four traditional

birth attendants, seven primary school teachers, and three secondary school teachers were incorporated into

fi ndings. Observations with service quality standard checklists were carried out at 16 primary school classes, eight

secondary school classes, homes of four TBAs and two bidan desas, six subdistrict health centers and two sub centers.

Water fi lling and supply facilities were observed for two Small Scale Independent Water Providers (SSIPs); 16 school

sanitation facilities and 23 household sanitation facilities were observed. Teams spent a total of 42 person-days in the

fi eld between October and November 2005.

1. 2. Identifying and Engaging with the Poor

It is easy to miss the real poor while carrying out community level consultations or research. The poor, who are

at the bottom of the social ladder, rarely attend community meetings. They cannot aff ord to take time off from

work and often they are not invited to meetings. From past experience, the poor have no reason to trust outsiders

and talk freely about their experiences, which are often very diff erent from the glossed-over versions repeated by

formal leaders. Researchers were equipped with a sequence of participatory analysis and qualitative research tools

(described in Annex 1, pg. 1-4) designed to address the communication barriers described above and gather views,

assessments and experiences of the poor.

Four research teams of four people each spent four to fi ve days in each community. Each team had two men and

women from NGOs or academia who held sessions with men and women’s groups. They explained the purpose of

the study, fi rst to the formal leaders of the communities and then to the poor.

The interest at each site was high. No one had asked the poor about their views regarding basic services before.

They were at fi rst surprised, and then expressive in their assessments and explanations. As work progressed, visual

analysis tools attracted participants and attendance grew. No incentives were off ered for participation and none was

needed. The group sessions resembled enjoyable social events which lasted late into the evening.

1. 3. Local Well Being and Poverty Profi les

For detailed information on sites and poverty, see Annex 2, pg. 5-12. It is particularly interesting to note diff erences

in who is considered poor by local standards compared to offi cial standards.

PAMINGGIR: Paminggir, a remote village of 333 households in kecamatan Danau Panggang, district Hulu Sunggai

Utara in South Kalimantan, is classifi ed as a “left behind village” by the GOI program Inpres Desa Tertinggal. Half of the

households are poor, by local standards. Well-being is measured in terms of one’s control over means of livelihoods,

i.e. boats, fi shing equipment, fi shponds, and buff aloes. The poor are defi ned, in contrast, by what they do not have.



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The village is accessible only by boat, two to six hours away from the district capital. The community depends on the

river for its livelihood, fi shing, as well as transport. Land is swampy, unsuitable for crops. Rainfall is heavy and fl ooding

is frequent. The community has one public primary school, a secondary school and a sub-health center open two to

three days a week. The nearest bidan desa is six kilometers away, the nearest health center 14 kilometers and diffi cult

to reach. The village has no clean water source or sanitation facility. Paminggir received a state electricity corporation

(PLN) connection in 1999.

BAJO PULAU: Bajo Pulau is a small village with 380 households on a 91 hectare island off the coast of Sumbawa in

Kecamatan Sape, West Nusa Tenggara. Most households depend on fi shing. Two decades ago, they used explosives

and potassium cyanide to fi sh; since 1987 they have focused on lobster and pearl harvesting, which provides better

income. There is little infrastructure; there are no puskesmas or private doctors on the island. Clean water has to be

brought from another island. There are three run-down primary schools, which function two to three hours a day.

Schoolteachers and bidan desa do not live on the island; the Bidan is thus rarely available when needed.

ALAS KOKON: This village of 508 households is in district Bangkalan, Kecamatan Modung, on Madura island. It has a

high 46 percent poverty rate by the BPS poverty map and 80 percent poverty rate by BKKBN criteria. The community,

using local standards, puts the poverty rate at 67 percent. Households are dependent on seasonal dryland agriculture

(corn, soybean, chillies, legumes and seasonal crops such as mango, banana and silk cotton—kapuk). Alas Kokon has

one public and one private primary school. There is a Pustu/Polindes in the village; the Puskesmas is seven kilometers

away. Clean water supply in dugwells is limited in quantity and sanitation access is minimal.

KERTAJAYA: Farmers grow fi ve tons per hectare of rice in the fertile soil of the West Java village of Kertajaya in

Subang district, Kecamatan Binong. Of the 1159 households, only 197 households are land owners; none of the poor

(63 percent of the population) own land. The village has good access to markets and is connected to Subang, the

district town, by bus or motorbike taxis. Houses of the rich on the main road have PDAM water connections others,

including the poor, use dug wells. A puskesmas is fi ve kilometers away; a bidan desa lives in the village. Kertajaya has

two public and one private primary school.

ANTASARI: This urban kelurahan in Kecamatan Amuntai Tengah, district Hulu Sungai Utara, has poverty rates of

more than 30 percent (BKKBN). The population is a mix of people from various parts of Kalimantan and Java, Sumatra

and Sulawesi. The Kelurahan has 1,243 households engaged in a variety of trades and services. The poor in Antasari

are mostly wage laborers in markets, at construction sites, and seasonal fi shers in the river. Education and health is

accessible (two public primary schools, one public secondary school, a puskesmas). Although PDAM provides piped

water to homes of the better off , the poor are not connected.

JATIBARU: The urban kelurahan in Bima city in West Nusa Tenggara Province is located in a fl ood-prone area. The

livelihoods of 1,886 refl ect an urban/rural mix: in the agricultural season the poor are wage laborers in farmlands of

neighboring Bima city, in other seasons they collect and sell fuel wood or work as vendors or day laborers in brick


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kilns and factories. Jatibaru has fi ve public primary schools, two public secondary schools, and one Pustu served by

three health workers; a Puskesmas and a public hospital are within two kilometers. The poor get their water from

unprotected dug wells and shallow bore wells; a piped water system built by CARE has fallen into disrepair: “The

community has no funds to repair” was the reported reason.

SIMOKERTO: Simokerto is an urban village in kecamatan Simokerto, district Surabaya, in East Java Province. The

village, 10 kilometers from Surabaya, situated in the middle of commercial and industrial areas, has a 90 percent

poverty rate (BKKBN). There is little social cohesion among the approximately 3,500 households: some live in a

squatter settlements on land owned by the state railways. The poor struggle to survive through a variety of work.

There are no health services in Simokerto, but Pustu and Puskesmas are nearby. Simokerto has eight public primary

schools, two private primary schools and a private high school. The nearest secondary school is three kilometers

away. A few rich have PDAM connections. The rest buy clean water from vendors. The poor mostly use dug well

water. Some houses have unimproved sanitation facilities that directly discharge into drains and black-colored

streams. Poor squatters have no sanitation access except one public toilet.

SOKLAT: Soklat is an urban village of 2,881 households. 54 percent of the households is poor (local criteria) in

kecamatan and district Subang, West Java Province, three kilometers from the Kecamatan capital. Though classifi ed

as urban, the region has irrigated rice cultivation and about 40 percent of poor households’ income is derived from

agricultural labor. Others work at construction sites, in shops, or pull carts as transportation laborers. A large proportion

of poor households send members overseas for wage labor. Agents regularly visit the village to recruit people and

provide loans for travel expenses, thus binding the recruited people into exploitative service agreements.

2. Education Services Used by the Poor

2. 1. Primary Schools: Not Really Free – Despite Government Provisions

Lack of education is a basic fact for the poor in Indonesia. At six of the eight sites, the poor cited one of the

characteristics of poverty as: “Children of poor households are often not enrolled in primary school/do not complete

primary school/just manage to fi nish primary school.”

In July 2005, the Indonesian government promised to provide nine years of free basic education for all school aged

children via Operational Aid for Schools (BOS) grants. Nonetheless, the poor still pay hefty entrance fees (sometimes

called building fees), particularly in Java (see Annex 3, Table 3.1).

Although students reportedly are no longer paying monthly tuition fees (which ranged from Rp.2,000 – 17,000

per month), cost of books, uniforms, fees for computers, examinations, and certifi cates can add up to Rp.100,00

– 150,000 per child per year. Additional “hidden” costs include shoes (required by some schools), school bags, snacks,

etc. (see Annex 3, Table 3.1).



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Top Choice: SDN

The poor prefer public schools. At most sites there was some choice among several government-run primary

schools (Sekolah Dasar Negeri or SDN), and in some cases also community-managed Islamic schools (Madrasah

Ibtidaiyah). At seven of the sites the primary school chosen by most of the poor was the SDN. The factors that the

poor mentioned in making this choice were:

• The SDN is near home; no transport costs; children can go alone; no need to cross main roads.

• SDN is free for the poor.

• Teachers are good; children learn many things in SDN. In Madrasah they get only religious teaching.

• Children fi nishing the SDN receive a certifi cate.

The only site where the Madrasah was preferred was Alas Kokon in Madura. Parents’ reasons for this choice:

• The Madrasah does not require costly uniforms.

• Teachers are more disciplined and regular at the Madrasah. The SDN teacher is often absent/not disciplined

• SDN only teaches children to read, write and count. At the Madrasah they also learn religious practices and

Qur’an reading.

Poor men and women generally think the benefi ts of primary education at public schools outweigh the costs (see

Figure 1 and Annex 3, Figures 3.1 and 3.2,). However, paying for that education, particularly when there are several

children, is a challenge.

Satisfaction ratings depend on the quality of individual teachers and the degree of transparency in the school’s

fi nancial dealings with parents (see Box 1).

The Burden of Additional Fees

The poor feel burdened by the cost of schools:

- “Why must books be changed every semester?”,

- “Why not have books that work for the whole year?”,

- “Why do school books cost so much?”,

- “Why are we charged for certifi cates?”

are recurrent questions. Unpaid entrance and certifi cation fees pile up. Schools increase the burden by withholding

passing certifi cates from defaulters, causing frustration and friction between poor parents and school authorities.

Even the kepala dusun (head of hamlet) of Simokerto had trouble paying the registration fee (typically kepala dusuns

are better off than the rest of their community). Only one of his three children received the school certifi cate after

full payment of the Rp750,000 (US$75) fee, roughly equivalent to three and a half months income of a local poor

household.


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Figure 1. Proportion of votes for choice of provider for primary education services

86%

14%

SD Negeri Madrasah Ibtidaiyah

78%

22%

Women’s View Men’s View

Education costs at the SDN vary widely among the sites (see Annex 3, Table 3.1). In Paminggir (South Kalimantan),

school is almost free with only nominal enrollment and school completion certifi cate fees; in the Surabaya slum,

enrollment fees and books amount to Rp.830.000.5 At West Java sites, parents pay 10 to 15 times more than elsewhere

to obtain primary school completion certifi cates. At Soklat, the men’s group complained that despite having paid

Rp.68,000, they still had not received the certifi cate. (In comparison, the privately run Madrasah Ibtidaiyah costs only

Rp.5,000 – 10,000 per month).

Box 1. No Explanation of Fees“We heard that in SDN Cibarola, at the time of getting the certifi cate, all the parents were invited to a meeting and informed that it will cost

Rp. 60,000. They were also informed of details of the cost. But in SDN Ds. Samsi, we parents were never informed nor invited to any meetings. I

have contributed several times – the total comes to Rp. 68,000. Why is it more than in SDN Cibarola? I asked the school principal but I was not

heard. And the certifi cate is still not given. Every time I ask, the principal says – later, later”.

Father of a child fi nishing primary school, Soklat, West Java

2. 2. Secondary School Education Services

“Free? What free? We don’t have to pay monthly tuition now, but we have to buy books and uniforms and pay building

maintenance fees. In the past we just paid Rp.10,000 – 20,000 every month and nothing else. Now we have to spend

Rp.200,000 at the start of the year.”

- Vegetable vendor and mother of two school children in Jakarta

Reported in The Jakarta Post, July 17, 2005

5 Registration or building fees range from Rp. 50,000 – Rp.100,000 per child at the NTB urban and West Java rural sites. The fees, which may be paid in

installments, reportedly cause many students to drop out. In addition, recurrent costs other than tuition (books, computer fees, uniforms, bags and

shoes, etc.) added up to Rp.100,000 – 150,000 per year.



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Extra Fees a Problem, again

Public junior high school represents a major fi nancial burden for poor families. Poor households try to send at least

one child to junior high school—Sekolah Lanjutan Tingkat Pertama (SLTP) or Sekolah Menengah Pertama (SMP)—

but can rarely aff ord to send all.

Only three children from Kertajaya village go to secondary school — and that is an Islamic boarding school (Pesantren)

outside the village. Bajo Pulau has no secondary school and no children are sent to study outside the village.

At urban sites Jatibaru, Simokerto and Soklat, respondents enrolled at least one child in SMP or Madrasah, whichever

is available and not too far from home. They prefer the Madrasah as there are no entry or construction fees. Entrance,

registration, and building fees are not fi xed, ranging from Rp.200,000 – 600,000 (see Annex 3, Table 3.2). The schools

charge whatever they can, depending on their reputation and popularity—and justify the fees on the basis of extra

subjects or facilities off ered. Reportedly, such charges have no legal basis.6 A comment from the men of Kertajaya

sums up the parents’ frustration: “To enter SMP Negeri calls for at least Rp.1.5 million. On top of that, there are the costs of

transportation, food etc. Who can aff ord it?”

Public Schools Most Popular, but Islamic Schools are Important

Pesantren or other Islamic schools (Madrasah Tasanawiyah) were chosen over SMP by 37 percent of the men and

women in the study, and were the popular choice at two sites, Alas Kokon and Antasari (see Annex 3, Figure 3.3).

Kertajaya and Bajo Pulau have no secondary schools and the remaining four sites chose the SMP available in the

community.

In Alas Kokon and Antasari, parents who send children to the Madrasah Tsanawiyah (religious schools run by the

Government Department of Religious Aff airs) seem highly satisfi ed. In Alas Kokon, the school costs Rp.1,500 a

month; in Antasari, annual fees are Rp.100,000, but all children received fi nancial aid this year. It is a “model” school.

Its services are complete and parents consider it very good value for money.

The SMP in Paminggir (South Kalimantan) is free, but the quality of the school facilities and education are very low.

Costs of the SMPs in Java and NTB are much higher (Rp.400,000 –600,000) (see Annex 3, Table 3.2).

When fees are charged the poor think that the SMP Negeri does not off er suffi cient value for the cost, whereas the

Madrasah Tsanawiyah does. Women are particularly dissatisfi ed because (see Annex 3, Figures 3.4 and 3.5):

• The SMP is far from home – transportation costs are high / not on public transport route.

• SMP is expensive. On top of that, it costs another Rp.450,000 to get the completion certifi cate (Simokerto).

• The classrooms are shared with the primary school (Jatibaru).

6 According to the Director of Paramadina University Center for Education Reform, Hutomo Danangjaya, state schools need no additional building

maintenance funds because they already have well-maintained buildings. Jakarta Post, July 17, 2005.


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Lack of Secondary Schools Means Girls Must Marry

Girls’ lives are drastically changed when the secondary school is inaccessible either due to distance or cost. In these

cases, the girls are married off soon after primary school and become pregnant just after they enter puberty (see Box

2). Maternal and infant deaths and disabilities are common in such pregnancies.

Box 2. Married at 13, childbirth at 14 –the only option after primary schoolOn September 15, 2005 in Alas Kokon village on Madura, researchers met Nurhayati who is 14 years old. She had just given birth to her fi rst

child after three days and nights of diffi cult labor. She was fi rst assisted by the local TBA, but later the bidan desa had to be called to help. She

did not die—this time. In the absence of a secondary school in the village, every girl in the area is married off right after primary school; im-

mediate pregnancies are inevitable, death is a high probability. How can Nurhayati and other young girls be empowered to gain any control

of their bodies and lives?

Site Report, Alas Kokon, Madura

2. 3. Quality of Services - Providers’ Views

Primary School Teachers’ Views

At seven sites the researchers met and interviewed teachers at state primary schools. At Paminggir, the night

watchman was substituting for a habitually absent teacher.

Teachers at rural primary schools state that they are able to provide very little in terms of quality education. Schools

have only two or three classrooms serving six grades. School buildings are in disrepair, but reports to the education

department bring no results. Rural schools in remote places like Paminggir and Bajo Pulau island have trouble

keeping teachers in school because of lack of basic services such as clean water and sanitation.

The teachers say that children tend to drop out and work, once they gain basic literacy and numeric skills. Parents

see no value in further education for their children. Sometimes a school will provide incentives such as funds for

transport or second-hand uniforms to encourage the poor children to stay in school.

The outlook of urban primary school teachers is much brighter. They believe they are providing very good value for

cost to poor students. They recounted the many pro-poor measures in place in the schools such as scholarships and

fund raising drives to pay for poor students’ uniforms, writing materials, and extra-curricular activities. In Antasari

and Jatibaru they said that parents know about the quality of the school and the pro-poor measures. At two urban

primary schools the teachers said that poor students do not have textbooks and suggested that the school should

lend books to the poor students.

Educators’ and parents’ assessments sometimes are far apart. The principal of the primary school in Soklat exalted the

quality of his school as “200 percent.” He emphasized that school administrators frequently interacted with parents,



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maintained transparency of funds, and allowed poor parents to pay fees in installments. Poor parents disagreed, and

complained that completion certifi cates were withheld and that information about waiver of tuition fees had not

been publicized.

Secondary School Teachers’ Views

The state secondary teachers interviewed were in Soklat, West Java and Antasari, South Kalimantan. In Paminggir,

rural Kalimantan, the village chief was serving as a volunteer teacher in place of the absentee state-paid teacher.

The teacher in Soklat argued that education could not be totally free, although the school does consider the

economic capacity of parents and allows them to pay the registration/building fee in installments. According to

him, the issue of education costs is over emphasized: “If they just smoke one cigarette less a day, it would be possible

to save enough to pay Rp. 15,000 a month for education.”

The principal of the Madrasah Tasanawiyah Model School in Antasari said government funds are suffi cient to cover all

fees and other study and extracurricular materials for students identifi ed as poor. Poor parents gave very high marks

for value and quality to this large school, which has seven to eight sections for each grade, totaling 23 classrooms.

This school is funded by the Department of Religious Aff airs.

2. 4. Independent Observation Results and Conclusions

Primary Schools- Quality of Service

Only state primary schools were observed. The four rural schools observed are in markedly poor condition, and

delivering signifi cantly lower quality services than the urban schools.

Although all primary schools are designed for Grades 1 through 6, rural schools had only two to three classrooms

necessitating grades to group together. None of the rural primary schools had clean water; half had no sanitation facilities.

Sanitation facilities at the other schools were present, but were damaged and unusable. None had electricity or a library.

Three had damaged roofs.

At the four rural schools attendance on the day of observation ranged from 28-92 percent. Classrooms were dusty

and littered, with damaged fl oors, but there were suffi cient chairs, adequate ventilation, and daylight. Wallboards

were the only classroom resources. No students’ work was displayed on walls. Frequently, students were left alone in

classrooms, without a teacher. Discipline levels were low.

Teachers did not live in the village but commuted from urban areas, and were often late or absent. Their reasons: lack

of clean water and sanitation services (Bajo Pulau, Paminggir, Alas Kokon), see also Box 3.


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Less than a quarter of the students in observed classes had textbooks and writing material. Teachers showed very

limited questioning skills and did not generate interactions with students. No student asked any questions in any of

the classes. Teacher displayed no gender bias in dealing with students, and used a mix of Indonesian and the local

language.

Box 3. No clean water equals no schoolteachers and health workers in the villagePak Sahrul, the school watchman/stand-in teacher at the Paminggir public primary school says government-employed teachers (Guru Negri)

are frequently absent.

“I enter the class and teach whatever I can when the teacher is not there,” he says. “It is better than letting the children waste their time.”

Sahrul says teachers live in towns, far away from the village, even though they have been provided free lodging. Paminggir has no clean water

supply and everyone has to use the river water for all purposes – cooking, drinking, washing, bathing, as well as defecation. The Guru Negeri

from the towns are not used to this. They return to the city to do their washing and are often late to report back to work.

Site report, Paminggir, South Kalimantan

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

NTB.

Box 4. 92 Enrolled but 29 presentTison dropped out of primary school in grade fi ve to help his family by working as a ferry boat operator. He now earns around Rp.100,000 (US$

10) month, giving most of his earnings to his father.

When asked why he preferred work to attending school, Tison said he had already learned to read, write and count and wasn’t learning much

else. Teachers came from the mainland, arrived late at 9 and sent the children home at 11 a.m.. School dismissed at 11 a.m. Grades 2, 3, 4 and 5,

6 were grouped together, consequently they were unruly and too big to manage. Surroundings were dismal: no water or sanitation facilities,

not enough chairs, and leaks in the roof. On top of that, Tison was bored.

On the island boys generally drop out of school between the third and fi fth grade, leaving mostly girls enrolled in primary school. On the day

researchers visited the school, only 29 out of the 92 children were present.

Site Report, Bajo Pulau, NTB

Urban Primary Schools: In contrast the urban schools were markedly better than their rural counterparts in terms

of facilities as well as teaching processes.



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Illustration 1: The Urban/Rural Divide: Conditions are good at urban state primary schools, as exemplifi ed by the

class in Soklat, West Java (left) and the school in Simokerto, East Java (right), which has a library

All four urban primary schools (SDN) had a reliable clean water supply. Sanitation facilities, while present and

functional, were minimal, with only one or two toilets serving up to 200 children. All schools had electricity and

suffi cient classrooms, but only two had a library and a sports fi eld. Two claimed to off er computer classes. Classrooms

observed were clean, well ventilated, and in good condition. Basic classroom resources like blackboards and wall

charts were present and used whilst chairs and tables for students and teachers were suffi cient.

Student attendance rates on the day of observation were a high 87-100 percent. At two sites, there were signifi cantly

fewer girls than boys.

Less than a quarter of students in observed classes had textbooks, copybooks and writing materials. The one

exception was SDN Murungsari 2 in Antasari, South Kalimantan, where more than three quarters of the students

had and used these learning materials during the class

Teachers present in all classes were well prepared and skilled in asking questions and engaging students’ attention.

Students, however, asked questions at only two schools. The teachers used local languages combined with Bahasa

Indonesia, checked for student understanding, did not display gender bias, and controlled their classes well.

Secondary Schools: Quality of Service

Illustration 2: Classrooms in the rural state primary

school of Bajo Pulau devastated by storms and fl ooding

three years ago.

In general, the quality of facilities available and education

processes of state secondary schools were far superior to those

observed at state primary schools.

Secondary schools were available and observed at all four urban

sites, but only at one rural site (SMP Negeri in Soklat, Simokerto,

Jatibaru, Paminggir and Madrasah Tasanawiyah Negeri Model in

Antasari).


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School buildings were permanent constructions; classrooms were in good condition, well ventilated, and adequately

lit with natural light. All urban schools had electricity and clean water supply available. Remote, rural Paminggir’s

school was supplied with river water pumped up to the school and generator-provided electricity. Two of fi ve

schools seen had libraries.

In three schools, two toilets were meant to serve 200-300 children and in all these cases the toilets were broken. In

two other schools six to eight toilets were well maintained. A separate toilet was allocated for teachers.

Illustration 3: Rural conditions are not conducive to

learning. At state primary school in Alas Kokon, grades

2, 3, and 4 are combined in one room. Children amuse

themselves—sometimes becoming quite rowdy—

because the teacher is absent.

The secondary schools had 6-23 classrooms at diff erent sites.

Except in Jatibaru (Bima) they were clean and in good condition.

On the day of observation, classes had upwards of 92 percent

attendance everywhere. Girls signifi cantly outnumbered boys

present (see Table 2). Reasons were not clear and warrant further

investigation.

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



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Table 2. Secondary school observations at diff erent sites

Present in observed classes

Girls Boys

Paminggir (South Kalimantan) 23 15

Antasari (South Kalimantan) 29 11

Jatibaru (NTB) 21 16

Simokerto (East Java) 35 8

Soklat (West Java) 21 23

More than three-quarters of the students were equipped with copybooks and pen or pencil, fewer than a quarter had

textbooks. Teachers appeared well prepared for their lessons. At two sites teachers taught only in Bahasa Indonesia.

At other sites they combined it with local languages.

Conclusions

1. Quality of primary education service in rural areas was observed to be very poor. The condition of the school

infrastructure was not conducive to learning.

2. Providing incentives to poor households for secondary schooling of girls or making it easier to send girls

to secondary schools can be a strategically important investment to delay teen pregnancies, give girls an

opportunity to gain control over their lives, and improve human development outcomes in Indonesia.

3. Teacher absenteeism was a key problem in rural areas that lacked clean water and sanitation—which reportedly

makes teachers from urban areas unwilling to stay in the villages. When they are absent, children are let out

of school, left in classes without teachers, or taught by teacher substitutes who have no training in teaching

methods and education levels no higher than secondary school. Most primary school students lacked textbooks

and writing materials, which lowered the quality of teaching and learning.

4. Lack of clean water and sanitation facilities in rural primary schools also made it impossible to inculcate basic

hygiene practices. Children observed had poor personal hygiene.

5. Urban state primary schools were better than rural schools in terms of basic infrastructure, except for sanitation.

Urban primary schools had teachers with adequate teaching skills. Most students lacked textbooks.

6. The quality of infrastructure and educational facilities, as well as the quality of teaching at the secondary schools

were far superior to those at the primary schools. This, however, made little diff erence to the poor since, according

to the study, children from poor households rarely progressed beyond primary school.


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7. Out of all the schools observed, the state primary school (SDN Murung Sari 2) and the state secondary school

(Madrasah Tasanawiyah Negeri Model, Sungai Malang), both in Antasari, seem to stand out above the rest,

followed by SMP in rural Paminggir. Ironically, these schools were charging the lowest fees and off ering the most

scholarships for poor students. All three schools are located in South Kalimantan. Parents are highly satisfi ed with

these schools, probably because the local government in South Kalimantan seemed to have made a dedicated

eff ort to fund quality education for the poor with a higher per student budget allocation than at other sites.

3. Health Care: Prenatal, Childbirth, & Child Health Services

The availability and aff ordability of the services and poor people’s perceptions of value and quality determine the

choices they are making. Typically, women make decisions about providers; men are involved only when expenditures

rise above Rp.10, 000. Each choice is highly rational, based on weighing of benefi ts and costs as perceived by the

poor. Policies to improve service delivery to the poor can be eff ective only if they are cognizant of the ways and

reasons the poor make their choices.

During the 1990s trained nurse-midwives (bidan desas) were introduced all over Indonesia in an attempt to lower

high maternal mortality rates. A decade later, bidan desas do not seem to have caused a large shift in the poor

population’s preference away from the traditional birth attendants (TBAs) for obtaining childbirth assistance

services.

3. 1. Prenatal Services: Preferences Vary with Geography

Approximately 65 percent of all the poor surveyed use public sector providers, i.e. the bidan desa, Puskesmas or Pustu,

while the remaining 35 percent use the traditional birth attendant known by various names such as dukun bayi,

dukun beranak, sando, paraji, bidan kampung (see Figure 2).

The TBA was the most popular choice at all sites outside Java. At the Java sites, both rural and urban, the bidan desa

or the Puskesmas/Pustu were preferred choices, except in Alas Kokon village on Madura.

Generally the pregnant woman or older female members of the household chose the ANC service provider. Costs of

the most used option and its closest comparators are shown in (see Annex 3, Table 3.3).



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Figure 2. Proportion of votes for choice of provider for ANC services

Women's view Men's view

34%

10%29%

26%

1%

Sando/Bidan Kampung/Paraji/Dukun Bayi Pustu

Bidan desa/Polindes Puskesmas

Posyandu

35%

14%26%

23%

1%

The poor who use the TBA for ANC services are aware that she is not well equipped to detect or deal with high-risk

pregnancies and that she does not supply vitamin supplements or TT immunization. They nonetheless chose the

TBA for the following reasons:

• The TBA is always available, whereas the Bidan is rarely in the local Polindes or Pustu.

• The TBA lives near their homes, while the Puskesmas is far away and requires costly transport.

• The TBA charges Rp.1, 000 to 5,000 per visit, sometimes just payable in rice or coconuts; the Bidan’s fees are

three to fi ve times that (Alas Kokon.)

• The TBA knows how to change the position of the fetus “if the head is not in the right position”.

• She is experienced, has delivered many healthy babies in the past.

• She is trusted and familiar.

At the Java sites where the Puskesmas and Pustu are more accessible, the poor preferred to make use of the

inexpensive public sector services. For Rp.2, 500 – 5, 000 they can get ANC examination, iron supplements as well

as TT immunization, and can also fi nd out whether the pregnancy is likely to be risky. Women prefer to contact the

bidan desa in the evening at the Bidan’s home for ANC services, because service is attentive and there is no waiting.

Costs, however, are fi ve times greater than the Puskesmas service when transport costs are added. Even on Java, the

poor spend Rp.6,000 – 12,000 on transportation to access ANC services, which cost Rp. 3,000-5,000 at the Puskesmas

or Rp. 10,000-15,000 at the bidan desa’s home.

Generally, ANC services from the TBA seem to provide the most value for money to the poor. The Puskesmas comes

second in this respect and the bidan desa, working from her home, is the third. (Annex 3, Figure 3.5, shows how the

poor rated the benefi ts of using each service provider and the extent to which they felt the benefi ts to be worth

the costs7 ). The TBA’s services are considered by women to be worth a lot more than the cost incurred (Bajo Pulau,

7 Benefi ts and Value for Cost is a tool from the Methodology of Participatory Assessment (MPA) repertoire. For explanation see Sustainability Planning

and Monitoring in Community Water Supply and Sanitation. Mukherjee and Van wijk , WSP-IRC-World Bank. 2003


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Alas Kokon, Jatibaru). Yet, at least at all the Java mainland sites, the poor were choosing the Puskesmas or the bidan

desa for ANC services rather than the TBA. They did this in order to minimize the risks of complicated labor and large

unexpected expenses during childbirth – through timely detection of possible high-risk pregnancies.

3. 2. Childbirth Assistance Services: TBA Still Reigns Supreme

Fees per birth assisted: SOKLAT / West Java

Paraji (TBA):

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

Bidan Desa:

Rp.300,000 - 400,000

As long as the birth is expected to be normal, the TBA is the most

popular and obvious choice everywhere. Barring the big city

slum site of Simokerto, at every site the TBA was the fi rst choice

among women (76 percent) and men (64 percent). (See Annex

3, Figure 3.7) Although the most obvious reason seems to be the

diff erences in costs, there are several other factors favoring the TBA. The bidan desa’s services for childbirth cost more

than an average poor household’s monthly income, and have to be paid for in cash. In contrast, the TBA can be paid

fl exibly in cash plus in-kind, at a rate about one tenth to one fi fth of the Bidan’s rate. The TBA is also willing to accept

deferred and installment payments – as and when the family can pay (see Soklat and Annex 3, Table 3.4).

More importantly, the poor are better satisfi ed with TBA’s services and feel they receive value for their money (see

Annex 3, Figures 3.8 and 3.9). The TBA is reported to be more caring and patient than the Bidan, both during labor and

after childbirth. Poor women say the TBA would continue to serve for 10 - 44 days postpartum, lovingly pampering

the new mother and the baby. She takes on all the washing and cleaning up after birth, sparing the family members

and allowing the new mother to rest and recuperate. In contrast, the Bidan is said frequently to be unavailable when

needed or even unwilling to come when called (Bajo Pulau, Paminggir, Alaskokon, Jatibaru). When she does come,

she assists only up to the delivery of the baby and the placenta.

The poor recognize that the Bidan is better equipped to handle diffi cult deliveries, but at six of the eight sites, the

Bidan is called only when the TBA is unable to deliver due to complications during labor, a practice that often leads

to fatal delays.

Professional jealousies further threaten the health of the mother and baby. The poor report that the bidan desa is

often unwilling to respond if the family has previously used the TBA’s services, and instead tells the family to go to

the Puskesmas or the public hospital. In West Java, the bidan desa has made a condition that if people want help from

the Bidan, they must call both the TBA and the Bidan to attend childbirth so that the Bidan can control the process

from the start. This however implies that the household incurs double charges.

The poor are seldom aware of possible problems during pregnancy or childbirth (see Box 5). They depend on their

chosen service provider (most often the TBA) to take action or refer the pregnant women to better health facilities.

The health care system fails to alert the poor to the danger signs of pregnancy or childbirth and what actions to

take.



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The public hospitals in Java and the Puskesmas are deemed to provide the most satisfying services (see Annex

3, Figure 3.8) but high costs keep the people away. The Puskesmas and the public hospital are used only in life-

threatening emergencies.

Box 5. Pregnancy danger signs unrecognizedTasiah, 36, fell down in her sixth month of pregnancy with her third child. She had visited the Posyandu and the TBA for ANC check up, but did

not report her fall and no one asked or reviewed risks. The baby was stillborn, dry and deformed at birth, and TBA said that there was no water

in the womb. The fall may have broken the amniotic sac long before birth, without the mother realizing it.

Site Report, Paminggir, South Kalimantan

3. 3. Curative Services for Young Children (< 5 Years): Public Services are the

Preferred Choice

At all the sites the poor tend to prefer public sector services for curative services for infants and under - fi ves. They

cite: better diagnosis, faster recovery, and aff ordability. From 80 to 85 percent choose public sector providers for

children’s’ health care mainly the bidan desa and Puskesmas (see Annex 3, Figure 3.10 and Figure 3.11). At urban sites,

the Puskesmas or the Pustu is the fi rst choice, at rural sites bidan desa or Pustu. Although private doctors are perceived

to provide better services, their fees are prohibitive (Soklat, Bajo Pulau).

Only the island community of Bajo Pulau, NTB, prefers the TBA. One reason is practical: the bidan desa was “never available

in the village”. Another relates to beliefs: according to local traditions, babies delivered by the sando (TBA) are considered

to belong to her for the fi rst 44 days of life and she takes care of them free of charge.

The poor consider a number of factors in choosing a health provider for their children under 5 years. Their most

important requirements echo their concerns regarding prenatal and childbirth services. The provider should:

• Be available when needed.

• Be close to home /no or low transportation costs.

• Prove aff ordable/good value for money (true mainly of the Puskesmas, since the bidan desa or mantri do not

accept Kartu Sehat outside the Puskesmas).

• Examine sick children thoroughly. When parents take the trouble to travel to the Puskesmas, their children

should get to see a doctor rather than paramedics.

• Only give medicines that are eff ective and clarify how long treatment is necessary before results can be seen.

• Explain to parents the nature of the illness and provide advice on how to care for the child (diagnosis,

prescription, medicines, immunization, supplements etc).

The poor consider their choices, and tend to make them by the degree of severity of the problem. They know that

the quality of service from the TBA is insuffi cient, but traditional healers are still consulted for minor ailments. The

comment of one parent was typical: “Traditional healers can only pray, off er massage, and herbal remedies, but can rarely

guarantee quick recovery.”


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The poor say the costs of consulting traditional healers and Pustu or Puskesmas are comparable, however they note

transportation to the Pustu and Puskesmas can signifi cantly raise the cost of seeking Pustu or Puskesmas services (see

Annex 3, Table 3.5).

In the villages, the poor with a Kartu Sehat (Health card) are attracted to the Puskesmas or Pustu, where they only pay

a “registration” fee of Rp.2,500 to Rp.3,000 to access services and free medicines. In Simokerto the Pustu “registration”

fee costs Rp.5,000 according to the poor, but Rp.3,000 according to service providers.

The previous points out a big problem in health care delivery for the poor. By law, the poor with a Kartu Sehat should

receive services and drugs at the Puskesmas for free. By charging a “registration” fee, the Puskesmas are collecting fees

illegally. By lacking information about set fees, the poor are consistently overcharged.

Services from the bidan desa at her home are highly rated, although the charge is roughly double, Rp.15,000: “There

is no need to wait in long queue and the medicines are more eff ective.”

If the child is still not cured, parents next consult the paramedic (mantri), who charges Rp.25,000 - 50,000, or a private

doctor at an average cost of Rp.40,000 - 70,000 per consultation, in addition to the cost of prescribed drugs. The

private doctor was the most satisfying option: “He gives medicines that make babies recover fast. One visit to the private

doctor is enough to the cure the baby.”

(Annex 3 Figure 3.12, shows how the top choice among service providers at each site measured up in terms of

benefi ts versus costs, in the perceptions of the poor clients).

3. 4. Quality of Health Services Being Delivered to the Poor

Observations by the Poor

Predictably, considering the fact that women are more involved than men in the care of sick infants, there is a gender

divide in satisfaction ratings of various providers (see Annex 3, Figure 3.13). Women are less satisfi ed than men with

services of the bidan (Soklat, Kertajaya, Bajo Pulau), the Pustu (Paminggir), and the Puskesmas (Soklat). While men

tended not to explain their ratings, poor women had many insights to off er about their experience.

Concerns about the bidan:

• “Why pay more at the bidan’s house, when she is the same one providing service at the Puskesmas [where it is only

Rp.3,000]?”

• “More than two to three times the cost of the Puskesmas”

• “Ibu Bidan is never available when we need her.”



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Reasons for women’s low satisfaction with the Pustu:

• “Workers are often not available, without prior information.”

• “Medicines given are not eff ective.”

• “We have to wait long in queues, even with a seriously ill baby.”

• “The workers just write down prescriptions and don’t explain how to give the medicines.”

• “They don’t tell the parents what is the baby’s illness and how to take care of the baby at home. They are always in a

hurry to fi nish with one patient and go to the next.”

• “Paramedics often make only cursory examinations for less than fi ve minutes. Sometimes, they don’t examine the

child at all and simply prescribe medicines after asking parents about symptoms.”

Dissatisfaction with Puskesmas:

• “At the Puskesmas those who examine the baby are not doctors, they are either the bidan or the mantri. There is no

doctor specialized for anything at the Puskesmas.”

• “For all illnesses they just give the same medicine. Often for babies they just give us a powder. I ask ‘Doc, what is the

fever my baby has?’ He says ‘Many things, mixed up’.”

• “They never explain the illness, or the medicine given to the patient. ‘If not better, come again next week.’ But if I come

again – the medicine will be the same again.”

Traditional Birth Attendants’ Observations on Quality of Care

TBAs were interviewed in rural Paminggir, Alas Kokon, Kertajaya and urban Soklat regarding their opinions of the

quality of services they provide.

The TBAs feel they are providing high quality, aff ordable ANC and childbirth assistance services. They say their poor

clients are highly satisfi ed, and see no need to improve their service. The Paraji in Kertajaya summed it up: “Helping

childbirth is our sacred human duty. People pay us whatever and whenever they can – rice, coconut, sugar, money. We

provide service for 40 days after the birth, day and night. That is why the poor are so happy with us.” The respondents’

votes for choice of ANC and childbirth assistance in this study certainly confi rm the truth of her statement.

Two of the four TBAs interviewed had received training from Puskesmas doctors in 1990-91. They had found the

training and the birthing kit given with the training to be useful.

An indication of how tight funds are: the TBAs are still using the same instruments – namely a pair of surgical scissors

to cut the cord. They wondered why training was no longer available, and suggested that the government should

provide them new birthing kits and a scale to weigh newborns.

The other two TBAs (in NTB and Madura) had refused the training and birthing kit. “I am too old to learn new things and

I don’t want to carry books and bag”, said the TBA from Madura. “My experience and traditional knowledge are enough

for my job.”


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This attitude probably refl ects the uneasy relationship between the TBAs who are old and respected members of

the community, and the bidan desa, a trained government employee from outside of the community, often younger

in age. Ideally the two should work collaboratively, but in reality, the TBA is reluctant to admit that the bidan desa is

better able to deal with diffi cult childbirths; consequently, references are sometimes tragically delayed.

Still, TBAs do see a need for improvements in the public health sector. The TBA in Paminggir said: “We need health

workers, Bidans and doctors who are willing to stay in the village, or at least visit the village on a defi nite weekly schedule.”

Bidan desa (Village Midwife) on Quality of Service

Bidan desas at six sites were asked their views about the issue. They said they were doing the best they can, but

observed that there is little demand for their services among the poor. Bidan Liliek in Kertajaya explained: “Some

of the poor choose my service because it is complete. I can detect pregnancy problems. I provide TT immunization and

vitamins. My ANC service fulfi lls standards.”

Bidan desas think they are charging fees commensurate with their services. They say that the poor unrealistically

consider them too high: “The poor expect miracles if they pay anything”, said Bidan Windarti of Alas Kokon. The Bidans

said they do adjust their fees to their clients’ ability to pay.

The bidan desas have several recommendations for service improvements that the government could make:

• More poor people need the Kartu Sehat or Askes insurance card. Often, when the Bidan refers the poor to the

hospital in an emergency, the clients do not have a health card.

• Increase the number and quality of drug supplies at the Puskesmas or Pustu, which the poor can access through

use of the Kartu Sehat.

Puskesmas/Pustu Bidan and Paramedics on Quality of Service

Urban Pustus (sub-health centers) may be losing customer bases. The Bidan in Simokerto said that only the poor

came to the Pustu, but even their attendance was falling. She suggested the center’s limited hours “might clash with

their working hours…. We used to serve up to 70 patients a day at this Pustu. Now it’s only 20 to -30 per day.”

Remote areas are more problematic: The mantri (paramedic) makes weekly visits to Bajo Pulau island to seek out

patients; people don’t visit the Pustu on the mainland. The mantri says people call him on his cell phone only if

someone is seriously ill.

Poor people can rarely fi nd the bidan or the mantri in the Pustu in Paminggir. The mantri said “I cannot stay in the

village as I have many tasks in the city.” The bidan desa, his substitute, doesn’t stay in the village either, because she is

reportedly preparing for the Haj. The villagers do not consider these reasons for their absence justifi able.



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Puskesmas Doctors’ Views of Quality of Service

Three Puskesmas doctors were interviewed in West and East Java (Madura) and NTB regarding services available and

their quality.

The doctors agree that the Puskesmas is valued by the poor mainly as a place to get free medicines and cheap

health services. They note that, in the past, medicines were in short supply, but now the Puskesmas is authorized to

buy medicine supplies using funds leftover from annual budgets. They worry that the poor have an impression that

generic medicines, which are sold or distributed without branded packaging, are less eff ective than the branded

ones.

The doctors were divided in their opinions about the quality of service provided by health workers to the poor. At

both the West Java sites they said the health workers provide good service at the Puskesmas; interact with poor

clients at Posyandus; and are trained in “quality assurance procedures”. According to them, one reason why the

poor are not fully satisfi ed with the clinics is because they are located far from their communities, which makes

transportation expensive.

All doctors state that the Kartu Sehat health cards have not been properly targeted at the poor. Many who have and

use it are well off , while a lot of the real poor still do not have Kartu Sehat or health insurance (Askes Card). Listing and

registration for Askes began in January 2005 and is not completed at the time of this study (October 2005). With fi xed

and inadequate quotas of clients per Puskesmas, Askes will not be available to all who need it.

The physician in the peri-urban Puskesmas in NTB said most of the outreach health workers were not providing good

quality services at the community level. To improve service quality he suggested the Depkes (Ministry of Health)

should:

• Establish practical performance indicators for health workers, which can be easily understood and verifi ed by

them and their clients.

• Institute rewards and sanctions for health workers as done in the private sector. Use standards like total patients

served per day.

• Deduct from health workers’ salaries when they are absent.

• Publicize the rights of the poor to health services through mass media.

3. 5. Independent Observation Results and Conclusions The study included an independent assessment of service quality and compared this with established norms. The

following conclusions draw upon assessments by the poor, by service providers, and the independent assessment

using observations guided by checklists.


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Ante Natal Care

The study reveals heavy use of the TBA for ANC and childbirth. This is not only because TBAs’ fees are low and they

are available, but also because the poor perceive the quality of their services to be high.

Poor men and women have little understanding about what constitutes good ANC services, and poor pregnant

women do not see periodic antenatal care as a priority. Their TBAs are generally not familiar with the pathological events

that may develop during pregnancy. The result is poor identifi cation and management of maternal complications or

risk factors, and a failure to benefi t from protective services like TT immunization and iron supplements. This leads to

elevated risks of maternal deaths, stillbirths, and neonatal deaths (See example in Box 6).

Box 6. Repeated premature births, no ANC check upsSri Wahyuni went into labor and delivered her fi rst child at only seven months of pregnancy. She was delivered at home by the local TBA. The

baby weighed only 2 kilograms, had diffi culty breathing, and the TBA could not clear her respiratory passages. The baby lived for only two

hours. Sri Wahyuni and her husband had no money for pregnancy check ups and had never gone to the Puskesmas for ANC examination.

The following year, Sri got pregnant again, did not go for ANC check ups, suff ered greatly from nausea during pregnancy and again went into

labor in the 7th month. The second baby was born alive, weighted only 1.4 kilograms and also did not survive.

Sri and her husband have given up trying to have a child. They don’t have money for pregnancy treatments, and are afraid of the mishap

repeating itself. Sri is using contraceptive injections every three months.

Site report, Simokerto, East Java

ANC by the TBA usually consisted only of determining the position of the fetus (with corrective massage if indicated).

Several undetected fetal deaths, maternal deaths, and stillbirths were attributed to this practice and the consequent

late referral for clinical intervention. TBAs lack of formally documented professional skills. For example, their level of

training does not allow them to make reliable estimates of delivery dates. The failure to follow standard care, e.g., not

giving tetanus toxoid immunization, results in infant deaths (Box 7).

The positive trend is that nearly two-thirds of the women and men interviewed reported using one out of three

other types of public service providers, i.e. going to the Puskesmas, Pustu or the village–based midwife. The need to

get the tetanus toxoid immunization for the pregnant mother was one reason they made at least one visit to public

service providers.

The observation checklists revealed that services provided by trained village midwives are relatively good. In general,

they follow the minimum standards. However, they tended to ignore the importance of health promotion/education.

During the initial evaluation of the patient, they tended not to ask about the profi le of the client, their obstetrical and

other health histories, and their socio-economic status. This could be due to the provider and the client knowing

each other as neighbors. Alarmingly, none of these providers washed their hands before examining clients. Physical

examination by the midwife consisted only of measuring the height of the uterus and the weight of the mother.



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They did not check the breasts, extremities, head and neck. Midwives usually provided tetanus toxoid immunization

and iron tablets. However, the midwives usually had to resort to purchasing these supplies themselves and charge

costs to their clients, resulting in fees higher than those charged by the TBA.

Box 7. No longer possessed by the devilBetween 1990 and 1996, 16 babies died in Rancajaya village. People believed that the devil possessed them. All had the same symptoms – convulsions,

high fever, their bodies turning stiff and bending like a bow. All were delivered by the local traditional midwife, who used a bamboo knife to cut the

umbilical cord. None of the mothers had received TT injections nor had the babies been immunized. When the babies got sick their mothers took them

to the midwife who massaged the child and prayed for its recovery.

Ibu Rusmini lost 3 children in this way, at 9 months, 1 month and 2 weeks.

Today, in 2005, people are aware of tetanus and try to get TT immunization for pregnant mothers. They however still use the services of the TBA for

childbirth. The TBA still cuts cords with a sharp piece of bamboo, which she now boils before use.

Site report, Kertajaya, West Java

During ANC examinations by the village midwife at or outside health centers, no women were informed about

those set by danger signs during pregnancy, which should prompt them to seek immediate care from trained health

service providers.

Childbirth Assistance

The study showed that most people were keen to use TBAs, as their defi nitions of quality service diff er from those set

by medical standards. The primary shortcoming of this seemingly superb service is the failure of most TBAs to meet

minimal medical standards, such as using non-sterile practices, e.g. cutting the umbilical cord with a bamboo strip

and aspirating the newborn’s nasal passages by mouth.

The case histories of maternal and fetal deaths in this study illustrate what happens when the TBA fails to respond to

the danger signs during pregnancy and labor and delays referrals (see Box 8).

Box 8. Four days too late …On Bajo Pulau island off the Sumbawa coast, Zubaedah was pregnant with her second child when she experienced abdominal pain and bleeding

in her third trimester. According to the sando (TBA) it was still too early for labor and the bleeding was “nothing much to worry about.” The wife of

the head of the dusun (Sub-village habitation), a trained midwife, thought the baby was already dead and urged the family to take Zubaedah to the

hospital, but they refused.

After Zubaedah continued to bleed for two days, the family decided to contact the bidan desa. She arrived a day later and, after examining Zubaeda,

the Bidan referred her to the hospital. After the journey to Sape by boat and rented horse carriage, Zubaedah was examined by doctors, who decided

to operate to extract the baby which had died because the placenta was blocking its passage out of the uterus. Before the operation could begin,

Zubaedah, exhausted from four days of bleeding, died.



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Curative Treatment for Children Under 5

The health center (Puskesmas) is the preferred provider. People consider it inexpensive and reliable. Nonetheless,

convenience compels most of them to bring sick children fi rst to village midwives or paramedics available in the

village. When the poor take the time and incur expenses to go to the health center, they hope that their children

will be examined by doctors or even specialists, not just paramedics and the midwife. Examinations by the latter are

considered too rushed (confi rmed during independent observations using a checklist devised by a doctor).

Assessment and classifi cation: Observation results reveal that very few sick children seeking care at the health

center were fully assessed and correctly treated by the midwife and paramedics. None of these providers washed

their hands before examining a sick child. Moreover, the quality of assessment and classifi cation of illness when

measured against the IMCI standards was low. Only one health care provider checked for the three danger signs. This

was at the one center staff ed by a doctor, and even he only checked for two of the three standard signs.

Treatment: In the absence of defi nitive diagnoses as the basis of judging the quality of treatment, the data cannot

gauge the appropriateness of treatment in this study.

Advice and counseling given: The study reveals a pervasive absence of health education services at every level of

care encountered by pregnant women, new mothers, care givers of infants and sick children. Providers did not explain

their diagnoses nor did they advise parents/guardians about ways to care for the sick children. If an explanation was

given, it was hurried and one way. Before moving on to the next patient, they rapidly stated instructions about

medication to be given but did not check whether the explanation had been understood and whether the parents

were clear how long the medication should be given.

When health service providers fail to counsel poor parents about infant nutrition and the need for immediate

treatment for diarrheal dehydration, children’s lives are put at risk ( See Boxes 9 and 10).

Box 9. How to feed my child when breast milk fails?Parhan was born a healthy 3.5 kilos, the fi fth child of his 38 years old mother, Hoiriyah. Parhan is now 20 months old, and underweight, weighing only

6 kilograms. He is often sick, and cannot stand or walk.

Hoiriyah stopped producing breast milk seven days after Parhan’s birth. From then, he was fed water only until he was one month, when he was also

given boiled rice. His parents have taken him to the bidan desa often to cure diarrhea, for which she gives them ORALIT but no nutritional advice.

Parhan’s family still does now know how to feed the baby.

Health workers at the nearest health center mentioned that this is a frequent pattern in the region, but they have not devised corrective or preventive

approaches.

Site Report, Alas Kokon



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Box 10. Diarrheal death of infant - close to services in a mega citySix month old Keni suff ered a bout of sudden diarrea and vomitting. Her parents took her to the nearest Puskesmas , which was understaff ed due to

a national holiday. Keni waited a long time to be examined, by which time she was severely dehydrated . She was referred to the city hospital. No one

told Keni’s parents that delay in getting Keni to the hospital could be fatal.

Keni’s father did not have a health card. Afraid that the hospital will cost much money, he delayed taking Keni there. Instead he went home to contact

his neighborhood chief (Pak RT) to get a letter certifying that he was poor, which would get him free hospital treatment. By the time he got the letter

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

Site report, Simokerto, East Java

None of the poor respondents in the study knew about an offi cial Health Ministry provision (Danareksa) by which

the bidan desa can provide services to the very poor needing her help in an emergency, and claim reimbursement of

her own fees/costs from the Puskesmas. If they had been informed, many of the poor could have been encouraged

to contact the bidan desa early; many of the deaths in complicated child births might have been avoided.

4. “Clean” Water Services Used by the Poor

Poor Indonesians do not have access to public water services and buy water at 15 to 33 times the utility’s water

tariff .

4. 1. Poor Lack Reasonable Access to Potable Water

In rural areas 40 percent of the poor were using unsafe water sources (unprotected dug wells and rivers) for drinking

and cooking (see Figure 3). Another 22 to 25 percent were buying water from vendors whose methods of carting are

often unhygienic. In Bajo Pulau, for instance, a vendor transports bore well water from another island in open drums

stowed in a boat hull lined with a dirty tarpaulin. In Simokerto water is sold in old, discolored plastic jerry cans.


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Figure 3. Proportion of votes for choice of Water Services used


11%

32%

5%22%

10%

8%

13%

River (no clean water supply) Unprotected dugwell

Borewell with pump (neighbor's) Vendor reselling PDAM water/borewell water

Public handpump Buy PDAM water from neighbor

Protected dugwell

14%

26%

4%25%

11%

12%

8%

In urban areas, not a single poor household was connected to utility networks. The poor buy PDAM (District Water

Company) water from neighbors who are connected or from vendors and pay 15 to 33 times the rate PDAM charges

low-income customers. Because they must go through many middlemen for their water, the poor pay six to eight

times more than the most affl uent households in Indonesian cities pay.

The poor are typically not aware that they are paying exorbitant rates because they pay small sums for small,

incremental amounts of water. Poor people often believe that they cannot aff ord to connect to piped water supply,

which could be true given the connection fees and the fact that they often live far from the network feeders. But the

poor are certainly able to aff ord water consumption at PDAM rates, since they already pay many times more than

that rate (see Box 11).

4. 2. Water Use and Health Hazards

Potable water is a precious commodity for the poor, who reserve it for cooking and drinking. Washing and bathing in

clean water is a luxury they cannot aff ord. At all sites, poor people bathe and wash clothes in rivers, at unprotected

dug wells or even in seawater.

This has important health implications. The strong cultural preference for defecating in running water has led to

an ingrained habit of defecating in natural water bodies. Several participatory evaluations of water and sanitation

projects8 and the Baseline Survey for the WSLIC project conducted by the University of Indonesia in 2003 found

that: “Almost all people wash their clothes, take a bath and defecate at the river even though they have a well. Defecation

in the river is perceived as ‘clean’, as it does not create a bad smell, like defecating in a poorly ventilated toilet.” People also

often throw garbage in the river and use the same river to wash their livestock, clothes and motorcycles—as well

as themselves.

8 WSP-EAP , 1997, 1999, 2000



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Those who do not wash and bathe in rivers and streams use water from unprotected dug wells without boiling.

In the Surabaya slum, water is “reddish, brackish and smells bad”. In Soklat the wells had no cement platforms and

were surrounded by muddy, stagnant pools. In Jatibaru, the walls of the dug well are made of old metal drums

used for storing industrial chemicals. The wells are located next to stables and have no cement platforms to prevent

environmental pollutants from seeping in. Solid waste garbage has blocked existing drains so that wastewater

stagnates around wells.

In people’s minds, well water is “clean”, while river water is not. Thus, those who are able use well water to wash and

bathe consider themselves fortunate, regardless of the condition of the well. Levels of satisfaction with well water

tend to be high unless the water is visibly colored, has a bad odor or is brackish. (See Annex 3, Figures 3.14 and

3.15).

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

Perception:“Pak Ketua RT (the neighborhood head) says we can’t aff ord a house connection to the PDAM’s piped network because the connection cost Rp. 750,000

($75) is too high for us. What is more, now that PDAM’s tariff s have increased from Rp. 300 to Rp. 700 per cubic meter, the monthly costs of water

consumption will also be unaff ordable for us. We spend only Rp. 300 everyday to buy 30 liters for drinking and cooking. We buy it from our wealthier

neighbors in buckets, paying Rp.100 for 10 liters”

Kalimantan Women’s Focus Group, Antasari, South Kalimantan

“We can never hope to get a household water connection from the PDAM. It will cost at least Rp.3 to 5 million, because the pipeline will have to cross a

railway line, a highway and a market, to reach Simokerto where we live. Who can aff ord it? Moreover, we are not owners of this land we live on so we

can’t apply for water connection. This land belongs to the State Railway company (Perusahaan Jalan Kereta Api)”

Men’s Focus Group, Simokerto, Surabaya

Reality:

The poor in Antasari are paying their neighbors Rp. 100 for 10 liters of PDAM water. This implies a rate of Rp.10,000/cubic meter of water—more

than 13 times the PDAM tariff s of Rp. 700/cubic meters. The poor in Simokerto buy re-sold PDAM water from a vendor at Rp.1,400 per day for 50

liters of water delivered to homes (or Rp.700 per day for 50 liters if collected from the vendor’s outlet). This implies a rate of Rp.28,000 per cubic

meter of water delivered at home. The current PDAM tariff for household connection in Surabaya is only Rp. 850 per cubic meter

4. 3. The Poorest Pay the Highest Price for Water

Water is costly. The poorest households—which comprised between 51-73 percent of community households at

diff erent sites—spend from a low Rp.5,000 (Jatibaru) up to a high Rp.60,000 (Bajo Pulau, Antasari, Simokerto) a

month for water (see Table 3). This means that the poor can spend as much as 15 percent of their income for

drinking and cooking water (Bajo Pulau).

The costliest water is bought from vendors. The cheapest way for the poor to obtain clean water was to collect it

from the mosque or a well off neighbor. In rural areas, this is usually bore well water; the poor pay about Rp.5,000


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a month to cover electricity costs of pumping it from wells. In the city, poor people collect PDAM water from

neighbors’ homes paying them about Rp.30,000 a month. In Soklat and Kertajaya, the poor spend about 30 hours a

month collecting dug well water from neighbors’ wells or public wells. Households in Alas Kokon spend 150 to 200

person hours a month hauling water for washing, cleaning and watering animals. Women in that village say it takes

them “two to three trips to the river to bring back water from the river, walking 1.5 kilometers each time”. Along with

washing and cleaning, “that adds up to more than three hours everyday”.

Table 3. Costs of clean water services and water use by poor household at 8 study sites

Rural Sites

Paminggir/S.Kalimantan

(River. No access to clean

water)

Bajopulau/NTB

(Bore well water from another

island, brought by boat by

vendor)

Alas Kokon/Madura

(protected public dug well)

Kertajaya/W.Java

(public handpump)

• Drink river water, after

sedimentation and boiling

• Bathe & wash in the river

• Defecate in the same river

• Rp.30,000 + 30 person hours/

month for 35 liters/day

• Buy water only for cooking &

drinking (Rp.30,000/month)

• Bathe & wash in the sea

• Defecate on the beach

• Quota 20 liters/day/

household,only for cooking &

drinking, time cost 8-10 hrs.

per person/house/month

• No payment

• Collect river water for other

purposes, using 210 person

hours/house/month

• Use simple pit latrines at/

near home

• 30 person hours per month &

Rp.5,000 for buying cooking

& drinking water from

mosque

• Bathe + wash in river

• Most also defecate in the

same river

Urban sites

Antasari/S.Kalimantan

(buy PDAM water from

neighbor)

Jatibaru/NTB

(buy water from neighbor’s

bore well with pump)

Simokerto/E.Java

(buy PDAM water from

vendor)

Soklat/W.Java

(neighbor’s dug well

– unprotected)

• Rp.30,000/month for 100

liters/day at Rp.100/10 liters,

only for cooking & drinking

(>13 times the PDAM rate in

the small town*)

• Bathe + wash in river

• Use unimproved pit latrines

at home

• Large % defecate in the same

river

• Rp.5,000/month for sharing

electricity cost. Collect about

120 liters bore well water/day

for cooking & drinking

• Bathe + wash at neighbor’s

unprotected well (no cost)

• Most defecate in the river

• Rp.42,000/month for 50

liters water delivered home

everyday, for drinking and

cooking (>30 times the

PDAM rate)

• Bathe + wash at public dug

well

• Defecate in pit latrines at

home/by railway line/ into

river/public toilets

• 30 person hrs./month per

household to collect water

for cooking and drinking. Boil

water for drinking

• Bathe + wash at well

• Half use sanitary latrines

shared with several

households

• Other half defecates in river

or pond

* Lowest PDAM tariff for house connections in Antasari = Rp. 700/cubic meter water.

Lowest PDAM tariff for house connections in Surabaya = Rp. 850/cubic meter of water



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4. 4. Observation Results: “Clean” Water Services

It was not within the purview of this study to carry out bacteriological tests of water samples at the sites. Observations

included: a) checking for the nature of the water sources used, viz. improved or unimproved sources according to

global MDG monitoring defi nitions9 , b) condition of water sources, and c) possibilities for contamination.

Illustration 5: Urban slum poor buy PDAM water resold several times—each

time the price increases. Bulk water seller fi lling small-scale provider’s jerry cans

from PDAM water stored in drum.

By these criteria, the poor at half the sites had

no access to clean water. They were drinking

and cooking with water from unimproved

sources open to various forms of organic and

chemical pollution. At the other sites, water

from improved sources was available in very

limited quantities, due either to the capacity

of the source, or the price of water.

The poor pay the highest prices,but get

the lowest quality. Because of the high rates

of the water vendors, the poor bought water

at 15 to 33 times the rate consumers pay to

utility companies. Because of the costs, none

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

water is used for a scanty fi nal rinse.

Illustration 6: Unprotected dug well, lined

with an industrial drum, in urban Jatibaru,

NTB. Water from this well is used for all pur-

poses.

.

Water vendors are unregulated and monopolistic. They collect water from

supposedly clean sources such as utility (PDAM) connections or bore

wells. However, water passes from large and medium scale water re-sellers

to small scale vendors, who use a variety of unsanitary means (used

chemical and oil storage drums, rubber hoses, funnels, etc.) to transport

water. There are no regulations requiring regular cleaning and periodic

replacement of these containers or equipments.

Contamination levels of the water fi nally reaching poor consumers

through vendors are likely to be much higher than acceptable norms, but

would require a bacteriological examination to confi rm.

9 The WHO-UNICEF Joint Monitoring Program classifi es improved water sources as protected dug wells, protected springs, tube well/borehole; rain-

water collection; public tap/standpipe; piped water into dwelling/yard/plot; and bottled water only when there is a secondary source that is also

improved.


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The poor consider dug well water to be clean. However, the physical conditions of dug wells and the surrounding

environments observed indicated that the water in all save one was and remains highly contaminated. Only Alas

Kokon had a protected dug well, but its capacity was limited. Poor users were allocated a quota of only 20 liters per

day per household, to be collected and stored once a week. This was used only for cooking and drinking.

Vendors have a vested interest in perpetuating their highly profi table, monopolistic hold on poor clients and have

been known to subvert other water supply options. Box 12 presents an example.

Box 12. Held to ransom by monopolistic water serviceBajo Pulau island has only one source of clean water – a private bore well three kilometers from the seaside hamlet of the poor. Because of the hilly ter-

rain, the poor cannot access that source. They survive by buying water for cooking and drinking from the vendor who transports bore well water from

another island. He sells the water at Rp.1,000 per 35-liter jerry can ( Rp.28,600 per cubic meter). The better off can buy three to fi ve jerry cans a day. The

poor buy one jerry can a day, aff ording 35 liters for a family of six to eight people. They bathe and wash in the sea, using the precious jerry can water

only for a scanty fi nal rinse.

The water is transported un-hygienically in the tarpaulin-lined hull of a boat and open drums. It is contaminated with dust and traces of oil. The water

vendor’s fi rst priority is to sell water to boats anchored at the port, and serve the poor community only with leftovers. Women often wait up to two hours

on the beach for the vendor to come. They can only helplessly curse the vendor if he fails to show up or runs out of water. They suspect that the vendor

intentionally damaged a government-built undersea water pipeline. Because the Public Works Department planned and built the pipeline without

involving the community, no local organization was established to manage and maintain it and it fell into disrepair.


4. 5. Quality of Services: Views of the Poor

Access to clean water is a prime determinant of quality of life. Having to depend on a water vendor’s whims frustrates

and angers poor women in Bajo Pulau: “We wait on the beach for the vendor’s boat. Sometimes we wait from the morning

and he comes as late as 2 in the afternoon. If his supply is fi nished serving the big boats in the harbor, we don’t get any. Just

wait for the day when he might need our help—then we’ll fi x him!”

Illustration 7: Water transported in boat’s hull to Bajo Pulau, a

rural island off Sumbawa coast, NTB

Urban poor who buy utility-supplied water from

vendors or neighbors (albeit at a high premium over

the utility rates) are highly satisfi ed with water quality

and price. According to the poor in Simokerto and

Antasari: “The PDAM water is clean, has no smell or color,

can be used without boiling, does not need to be pulled up

(from wells), and is aff ordable.”

This comment was surprising, considering the poor

were paying many times more than the PDAM rate per

cubic meter of water. It completely debunks the myth often stated by PDAMs that the poor are not profi table

customers because “they cannot pay cost-covering tariff rates.”



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In fact, many of the local poor work as water vendors for the cartels that serve designated slums. These cartels decide

the selling price for water and do not allow competition that might bring down prices. There are designated fi lling

stations in each Kelurahan supplied with a PDAM connection; consumers may buy their water at the fi lling stations

or have the vendor deliver it to their homes at twice the cost.

Illustration 8: Water vendor’s boat, Bajo Pulau, NTB

Because of the high prices, the poor only buy

limited quantities of clean water—just enough

for cooking and drinking. They accept as a fact of

life having to use unsafe water from polluted

wells and surface water sources for all other

purposes. Consequently, they had no complaints

about unsafe river water when it was available

and free.

Nonetheless, others recognize the impacts this

“free” water has on people’s health. The Mantri

from the health outpost in Paminggir comments:

“This village needs a clean water supply more than

any other health service. Each year there are numerous cases of diarrhea and skin diseases because the people use the river

for drinking and cooking as well as for all bathing, washing and defecation.”

5. Sanitation Facilities Used by the Poor

Water availability, water use practices, and sanitation practices are intrinsically linked, as amply illustrated in the

previous section. Sanitation practices refl ect what people consider clean, convenient and comfortable—and what

is available.

Figure 4 shows that, except for a tiny minority in Soklat (West Java), poor men and women at all eight sites have no

access to any kind of “improved sanitation facilities.”10

10 “Improved sanitation facilities” are defi ned by the WHO-UNICEF Joint Monitoring Program (used for global monitoring of MDG targets) as: venti-

lated improved pit latrines, pour fl ush latrines, simple pit latrines with cover, or connections to septic or sewer systems. This defi nition excludes bucket

latrines, open pit latrines, public or shared latrines, and latrines discharging directly into water bodies.


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Figure 4. Proportion of votes for choice of sanitation facility used


44%

8%9%

10%

25%

4%

River (open defecation) Field (open defecation)

Beach (open defecation) Unimproved pit away from home

Unimproved pit household latrine Shared household latrine

41%

17%

16%

11%

14%

The coastal Bajo Pulau community defecates on the beach at night or before down, so that the tide can wash away

the feces. At six other sites people prefer to defecate in the river, while washing, bathing and brushing their teeth

in the same river water (see Table 3). Defecation in the water leaves no visible excreta or obvious smell, and is thus

considered “clean” and in fact a “healthier option” than the smelly, simple pit latrines and public toilets available to

them—this despite the decades of eff orts by health authorities to push the health benefi ts of latrines.

Women (61 percent) and men (74 percent) said that they defecated in the open in rivers and small streams, beaches,

ponds, rice paddies and bushes. The use of natural water bodies is free, whereas there are long lines and a Rp.200

charge at public latrines in the urban Java slum. Unsafe open pit household latrines are used by another 25 to 35

percent. These are no more than holes dug into the yard (Alas Kokon, Jatibaru), directly beneath the home on stilts

in swamp areas (in Antasari), or by the railway track embankment in the urban slum (Simokerto).

There are gender diff erences in sanitation behaviors (see Annex 3, Figures 3.16 and 3.17). Privacy was reported as the

most important rationale for sanitation behavior, in conjunction with convenience and “cleanliness” (natural running

water). Regardless of the quality of the latrine facility, a household facility is preferred over having to go out for

defecation – particularly where homes are not close to the river or the sea (Alas Kokon, Antasari, Soklat, Simokerto).

Women prefer the household facility more than men do.

Another major obstacle to poor people gaining access to improved sanitation is the widespread misconception

about sanitary latrines being an expensive luxury. The poor are under the impression that latrines cost a lot of money



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(Rp.750,000 – 2,000,000, i.e. $75 – 200), and are therefore out of reach of poor households. In a country where half the

people live on less than $2 a day, such perceptions are rational. The misconception is born of poor people having

seen only expensive household toilets built by upper class households. Public Works departments have not helped,

by promoting only standardized engineering designs of high-cost options certifi ed as “hygienic”.

5. 1. Observation Results: Sanitation Services

The poor do not have basic sanitation services. This study found barriers to improving public sanitation to include:

1) public perceptions of open defecation into water bodies being a desirable practice; 2) widespread ignorance of

low-cost sanitation alternatives and misconceptions of sanitation being an expensive luxury; 3) lack of mechanisms

to eff ectively promote better sanitation and hygiene practices and low-cost sanitation improvement options.

In both rural and urban areas the poor use any natural water body available as the preferred sites for excreta disposal;

some do so even when they have latrines built at home through project- provided funds or subsidies, because of the

unpleasant and typically unsanitary conditions of the latrines. The result is a grossly under-recognized environmental

disaster that aff ects the living environment for the total population in Indonesia, both the poor and the non-poor

alike.

People use latrines when they are clean and convenient. At a Java peri-urban site, a small group of people had access

to sanitary household latrines built by a project. These latrines were reasonably well maintained and shared by four to

fi ve households. People were less inclined to use public toilets provided by an NGO, which were grossly inadequate

in number, poorly maintained despite a Rp.200 fee per use, and plagued with long queues in the morning.

Apart from these two instances, various forms of unimproved household toilets built by the poor were encountered

at half the sites. In the rural areas these were the bamboo poles or wooden slats over ponds or rivers, often temporarily

enclosed with fabric or makeshift wooden structures, or simply holes dug in the backyard.

Illustration 9: In Paminggir,

rural South Kalimantan, the

poor live on the river and use

it for everything: cooking,

drinking, washing, bathing and

defecating (right). Enclosure in

the background is a latrine.

In the urban areas these holes were

often cemented and incorporated

within dwelling units, but they

discharged raw feces directly into

urban drains or rivers. The poorest in

squatter and slum settlements do not

have even these holes. They seek out

public land with any semblance of

privacy for open defecation, or

defecate into urban rivers just as in villages.


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Illustration 10: Open pit household latrine in a backyard is

accessible to domestic animals, further expanding the chances

of the spread of diseases. Alas Kokon, Madura

Rural primary schools and half the urban primary schools

lacked functional sanitation facilities for students. The

urban and the secondary schools had functioning toilets

for students and teachers, but the ratios of students to

toilets were upwards of 100 to 1 at most sites, which

would preclude their use by all students.

The government has not dispelled the myth that sanitation

is expensive. The reality is that in most parts of inhabited

Indonesia today, it is possible to build low-cost sanitary

toilets using locally available materials and labor, at costs

ranging from Rp.100,000 – 300,000 (US$10 - $30)—within

the reach of the majority of the poor. However, there are

no programs to raise public awareness of the real costs

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

5. 2. Quality of Services: Various Views

Illustration 11: Household toilets exist in urban poor

neighborhoods they typically discharge directly into rivers or

drains behind homes which fl ow into urban rivers. Simokerto.

The quality of sanitation services for the poor is abysmal.

There is no visible eff ort on the part of local or national

governments to provide the poor with solutions for this

basic need.

In rural areas, natural bodies of water become ad-hoc

toilets, imperiling the health of the community. The Pustu

paramedic in Paminggir said:

“The biggest health problem here is the river, which is the

principal life support for the villagers…. It’s used for all

purposes by the villagers, including bathing, washing, cooking

and drinking, as well as excreta and wastewater disposal.

Diarrhea and skin diseases occur frequently; annual fl oods turn them into epidemics. We can treat diseases with drugs, but

we can’t prevent them.”

The lack of basic sanitary services impacts other services such as education. In rural areas, teachers often refuse to

stay in the villages—and consequently often don’t show up to teach. The volunteering local teacher at the Paminggir

primary school explained that the trained teacher is seldom in the village (even though living quarters are provided)

because there are no sanitation facilities. The offi cial teacher goes back to the city “to wash clothes” and is usually late

returning to his duties in the village. Local teachers at Bajo Pulau echoed these views.



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Illustration 12: Natural bodies of water are the preferred places

to defecate, as illustrated by this toilet over a pond in peri-urban

Soklat, West Java

There seem to be no norms governing basic water and

sanitation facilities in the construction of school

buildings. Primary teachers in rural Kertajaya said their

school had been built without any water or sanitation

facilities. They later received one toilet from the

Kecamatan Development Program (KDP)—one toilet for

the entire school, which proved inadequate and soon

broke down.

Similarly, there seem to be no funds set aside in local

budgets for routine and regular maintenance. In urban

Soklat, after the students’ toilets broke, the teachers

allocated one of the two teachers’ toilets for the use of

female students. Repairs had to wait for the next annual

government allocation, many months away.

Public pay toilets are a fi nancial burden for the poor. In the Simokerto slum settlement, the money collector at the

public toilet says less than 30 people a day use the toilet, although the neighborhood (RW) has 300 households, many

of which are within 100 meters of the toilet. He believes the Rp. 200 charged per use is too much for the poor to

aff ord.

6. Poor Have Little Client Power—But They Want It

The poor are disempowered. At all eight sites, it was clear that the men and women had little concept of their own

power or their rights as clients. The top-down approaches of the New Order era and feudal societies have left a

heritage of unequal relationships which extends to the relationships between the poor and their service providers.


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Box 13. “They give us no choice….”About 15 years back, all married women in Rancajaya village were forced to accept the spiral (intra-uterine contraceptive device). Women were round-

ed up by government workers and taken by pick-up trucks to camps for insertion of the spiral. Not a single married woman could escape. Women who

hid were chased until found. Those who refused or ran away had their houses marked with red strips for follow up.

Many women who received the spiral suff ered for months from pain and bleeding. Husbands were scared for the health of their wives and tried many

things. Some had their wives spend hours sitting partly submerged in the river or water tanks, hoping that the spiral would fl oat out. Nothing worked.

All those women and their daughters—now married with children of their own—are so frightened of contraceptives that they avoid using any.

“Health workers never give us information about diff erent types of contraceptives and what are the benefi ts and disadvantages of each type. Don’t be

surprised if in the women’s group discussions you fi nd married women who have never seen a condom!”

As related to researchers by the men’s group in Kertajaya, West Java

6. 1. Lack of Information-“We Don’t Know”

Illustration 13: Lost opportunities: In the ANC examination room, Soklat, West

Java, posters show diagrams of labor and reproduction system. There is no

information for women about danger signs in pregnancy, or protective services

available.

Typically, the poor have no direct access to

information of programs directed at them and

so have little or no idea of their rights. The

researchers did not fi nd any public material

publicizing what services are available (such

as Kartu Sehat, Askes and scholarships) or

describing how those services could be

obtained. Service outlets—Pustu, Puskesmas,

schools, and village government offi ces

(Kantor desa/Kelurahan)—simply did not have

supporting literature. Poor women asked: “Why

is there no information about these measures on

radio and TV, in posters in Puskesmas?”

In their own eyes and in the eyes of service

providers, the poor are passive recipients of whatever services and information the service providers or community

leaders choose to make available. They must depend upon community leaders (Ketua RT or Kepala Desa) to list them

as “poor”, and then depend on Puskesmas workers to dole out the quota of Kartu Sehat/Askes cards, or upon school

principals to award scholarships. Typically, poor are also at the mercy of water distributors—when they will deliver

and how much they will charge.

Confusion Regarding Pro-poor Services Available

The poor do not know accurately what fees should be charged for pro-poor services—a very central issue in

the lives of the poor. Because of the lack of information, none of the poor in the study knew about an offi cial Health

Ministry provision (Danareksa) by which the bidan desa is reimbursed for providing emergency services to the very

poor. Residents at two sites did not know about health cards. The poor said it was never clear which medicines are

free for Kartu Sehat users (Simokarto, Soklat, Jatibaru) and which not.



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At other sites the poor were aware of services such as cheap rice (Raskin) and health card. Information about school

fees being waived was well known at six sites, although they understood the school operation funds (BOS) program

to start as of September 2005 when in fact the date was July 2005. At Jatibaru (NTB) and Soklat (West Java), the poor

said they had found out late, from television. The primary school did not inform parents. In fact, in Soklat, parents

paid tuition fees for September 2005 before they learned that fees had been waived. The school has not returned

the money.

Frequently, the people were confused about what the pro-poor services provide and to whom. For instance,

at diff erent study sites quotas of cheap rice available to poor households per month ranged from 3 to 20 kilograms.

Many had questions about who was eligible for Kartu Sehat. They complained that few poor families received health

cards, while many non-poor did because they were related or close to the village chief (Soklat, Jatibaru, Antasari,

Paminggir).

The poor repeatedly said they didn’t know the duties of public sector service providers. This was particularly

true in reference to health workers manning the Puskesmas, the Pustu or outreach services.

It is not clear to the poor how decisions are made about services or who makes them. In Soklat, the poor

approached the Puskesmas to get Kartu Sehat, but most failed: “Everyone passes us on to someone else—no one gives

clear answers.” In Jatibaru, the poor asked the school about their children’s eligibility for scholarships. They were told

that recipients were “decided from above”.

6. 2. “Who Will Hear Us?”

What To Do About Bad Service?

Poor men and women are aware that they are often not served well, but don’t know what to do. Complaining to

local political leaders or the mass media is alien to most of them; they cannot imagine reaching such people nor

do they believe that these elites will pay attention. Residual memories of the harsh tactics of the Soeharto regime

stifl e most dissent. No one at any of the eight sites has ever seen or heard of a negligent service provider being

sanctioned in any way, regardless of the number of complaints. “We can’t even ask why we don’t get proper service, let

alone sanctioning anyone. We have no authority or power, even to ask questions,” commented women in Soklat, West

Java. The result is resignation: “The service provider has the authority to decide what services we can get,” was a typical

response in Jatibaru. Complaints might bring retribution. “If we complain, they will exclude us from distribution of things

like Kartu Sehat,” comments another from Simokerto.


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Fears About Complaining About Poor Services Abound

The poor are at the bottom of the community hierarchy. On densely populated Java where land is a highly prized

asset, the poor often do not own the land they live on, which creates a feeling of insecurity and fear of speaking

up. In Jati Baru, people claimed it was embarrassing (tidak enak) to complain about the Bidan and Pustu workers,

because they had family and social connections in the community; in Madura, the poor hesitated to go to the village

leader because “that will create more problems for us later”.

Some villagers did make attempts: In Kertajaya, West Java, the poor asked the village chief to require the bidan

desa to live in the Polindes (birthing clinic) built by the community. In South Kalimantan the villagers lodged formal

complaints with the local government (Dinas Pendidikan) about a primary school teacher who failed to show up for

classes, despite being given living quarters (Paminggir). None of these eff orts yielded any results. “The Bidan lives in

the town (Sape)”, noted women in Bajo Pulau. “If we call her she always has many excuses why she can’t come, including

even low tide! She won’t even get off the boat lest her feet get wet! But we are afraid to complain – she is related to the

Village Secretary, and he is powerful.”

The poor are not afraid of complaining about sanitation services—simply because there are no providers. The

poor do complaint about monopolistic water servers (SSIPs) in Bajo Pulau, but the complaints get them nowhere.

Urban SSIPs satisfy their customers—the exploitative price of the water is hidden by the fact that it is paid in daily

increments.

Community Elites Give Directions

Generally, the poor take directions from the people in charge—teachers, health workers, village leaders—regarding

pro-poor services (or the lack of them): “We keep quiet and do what they tell us to do”, said one resident of Soklat. “At

most we ask our Ketua RT (neighborhood head) if he can explain.”

Box 14. “Because I am poor, and therefore also stupid”Pak Yusuf has 13 children and earns a meager living working as a carpenter. Only one of his children has entered junior high; two others did not con-

tinue beyond primary school because of school fees and because they could not obtain a pass certifi cate from the primary school.

“I could not pay Rp.55,000 required for each certifi cate”, Pak Yusuf said, adding that he has pleaded with the school to reduce the rate, to no avail.

To get their child admitted to junior high school, Pak Yusuf and his wife off ered Rp.20,000 and their only valuable asset—a table fan—as registration

fee. He still wonders how to pay another Rp.50,000 for uniform and books. He never tried to obtain a letter from the local government certifying his

poverty, which could lead to fee waivers. He said: “I am only a poor man, and therefore also stupid. No one told me about this. I don’t know how to get

it although I do want to obtain this letter. My experience so far has always been that no one really wants to help me.”

Site report, Soklat, West Java

The Ketua RT is an important bridge between the government processes and structures and the people. In contrast,

the village chief, his assistants and the village governance apparatus are often too distant to be relevant to the lives

of the poor. The people of Bajo Pulau were particularly vehement about village offi cials: “The Kepala Desa doesn’t care



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for us. He never comes to our hamlet, even when someone dies. Just throw him into the sea!”, “That Village Secretary just

eats village funds!”, “The Badan Perwakilan Desa (BPD, the village council) is just a formality—has nothing to do with us.”

6. 3. Poor Treatment by Pro-Poor Service Providers and Offi cials

“We feel like stepchildren in the family. Possibly because we don’t own the land we are living on and not paying land taxes

to the village government. We have no right to expect any services from them ….”

Poor women’s group, Kertajaya

Many health card users said they had to wait at the Puskesmas until paying customers had been served; at the Pustu

they were sometimes simply ignored. Women in Kertajaya and Jatibaru said that the bidan desa would only assist

them during childbirth if they had gone to her for ANC services previously.

When they are examined by public health service providers, it is cursory at best; sometimes drugs are given without

examination. The poor said that they get the public service provider’s attention only when they pay fees at a private

facility.

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

Puskesmas on the mainland.

Box 15. Kartu Sehat users need patience and forbearance“The doctor who works at the public hospital in Jereng also practices privately outside the hospital. My wife had been examined by him at his private

clinic during her pregnancy. At the time of childbirth, because I had no money, I took my pregnant wife to the public hospital in Jereng, which is the

nearest hospital that accepts my Kartu Sehat. When we reached the hospital I was asked to fi ll out forms with information about my wife. Soon after,

the doctor who had examined my wife before, arrived and started scolding me because I had not taken her to the private hospital which he had earlier

recommended. I said I cannot aff ord the expenses of the private hospital – but the doctor kept shouting at me and my wife…..”

Bapak Sobirin, Kampung Rancajaya, West Java

6. 4. No Voice in Community Decisions and Service Provision

According to both women and men, decisions regarding the use of public funds are made solely by government

functionaries together with the formal community leader.

“There has never been a public meeting or forum to inform us about plans for local development or government fund

allocations to provide services to our community. If there is a community meeting, the Kelurahan workers do not publicize

it.”

Poor Men’s Group, Simokerto


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Sometimes, this high-handed approach on the part of offi cials has forced the poor to act on their own and provide

supposedly public services with their own meager savings. “Even though the Ketua RT and community representatives

are members of the Badan Perwakilan Desa, we never get to know anything about fund allocation for basic services,”

noted the men from Kertajaya. “We have sent formal requests to the village government many times to give us an offi cial

electricity connection. Now we are spending our own money on cables to draw power from another kampong.”

.

6. 5. Problems with the Participatory Process-“We are Stepchildren”

While poor men feel they have no voice in community decisions in general, and in basic service provision in particular,

poor women are even more on the periphery: “Women in the Kelurahan, if involved in any activity, are only from the rich

households”, said women in the Antasari Focus Group.

The women from Soklat were even more outspoken, “They never call us for meetings and discussions because they think

we are stupid, because we don’t have money, because our eff orts/ initiatives are small scale, because we are considered

‘small people’ (poor).”

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

are equal.

This state of aff airs distorts the quality of participatory processes and equity in outcomes of development projects

aimed at poverty reduction and empowerment of the poor. The following unsolicited comments, made during

focus groups about community-driven development projects (considered largely successful in Indonesia) illustrate

this point:

“We only came to know about the road-building work after laborers from outside the village were hired to build it, although

the road is meant for our community’s use, and the program was for providing wage income to our community.”

Poor men’s group, Antasari



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Illustration 14: The poor in places like Jatibaru, West Nusa Tenggara (left), and Paminggir, Kalimantan (below) claim that local elites will only

listen to their views through outside facilitators.

“The hand pump was installed entirely by project functionaries, starting from selecting the contractor and laborers until

construction. The result is a hand pump near the mosque, where the kepala desa wanted to put it. The water is salty. No one

uses it. The pump has broken down within one year of construction.”

Poor women’s group, Kertajaya

“We have never received any micro-credit services from the poverty reduction project. Those who did had some business

initiative of their own, and are the middle class people. The Badan Kerja Masyarakat (community management team for

the project) that decides the recipients is made up of people who are not poor. The poor people only get loan and saving

facilities from the private mobile banks that visit the community often.”

Poor women’s group, Soklat

Help Us Participate

Poor men and women did articulate that they can gain a voice in community life if outsiders support their eff orts.

The people of Alas Kokon explained their vision: Essentially, they believe they need facilitators from outside the

community who can organize meetings or create a forum for open discussion. These external facilitators must care

about the poor and they should have the skills to identify who the poor are in the community.

Residents of Alas Kokon were emphatic about the need for outside intervention: “Through government institutions/

workers, this kind of process facilitation is impossible. … Until now, we have not seen any government institutions that care

about the quality of services for the poor or about the aspirations of the poor.”


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7. Recommendations for Policy and Strategy

Following are a series of recommendations for general and specifi c policy actions and strategies to improve service

delivery to the poor. They are drawn from the specifi c observations, complaints and assessments made by the poor

at all eight sites. Based on personal, real-life experiences, these suggestions off er unique insights into the ways poor

women and men poor believe services could be improved and form a complementary list of actions to be used

along with fi ndings from the quantitative analysis in the main report, Making Services Work for the Poor in Indonesia.

7. 1. For Basic Services in General

1. Establish procedures that allow the poor to seek and obtain pro-poor services on their own without having to

depend on community leaders or service providers for procedures to access.

2. Eliminate poor people’s dependency on service providers and community leaders for information that aff ects

their lives and health, e.g. basic services available, their standards and costs, special provisions for the poor,

where and how to get.

3. The paradigm of the poor passively and helplessly waiting to get listed/ certifi ed at the discretion of their formal

leaders needs to be reversed. Certifi cations and classifi cations of who is poor and who is not should become

more participatory and be done through collective assessment methods that make it fully transparent and allow

local-specifi c poverty characteristics to be identifi ed and taken into account.

4. Create coordinated information programs to alert the poor to the services that are available to them and to

make them aware of the benefi ts of these programs. There should also be information programs alerting the

poor to danger signs—common situations that can and should be addressed immediately by them to avoid

harm.

5. Communicate directly with the poor about all pro-poor services through mass and institutional media. Publicize

pro-poor services and how to access them, e.g. through radio, regional newspapers, visual publicity materials

at puskesmas, pustus, public hospitals, schools, mosques, banjars, village/kelurahan offi ces and public transport,

information handouts distributed to households through neighborhood heads (Ketua RT), men’s and women’s

groups (arisan, PKK) and the like. Set up information kiosks in districts and kecamatans where the poor can go

to fi nd out about all pro-poor services available in the region from all public and private sector sources. Publicize

the presence of such kiosks.

6. Empower the poor with information on service standards that they should expect from each type of provider,

and what action to take when those standards are not met. Publicize these prominently at all relevant public

service outlets and make their permanent display mandatory.



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7. Establish mechanisms that make it easy and risk free for consumers to report on the performance of basic service

providers in comparison to the expected norms. The Kecamatan Development Program (KDP) in Indonesia has

fi elded several innovative methods of community reporting on corruption, which could be adapted for this

purpose. Develop ways for consumers to assess and report on performance of providers that do not require

consumer identities to be revealed, since social familiarity with the provider is often the constraint to reporting

on poor performance. Find ways to use the results of these consumer reports and link them directly to providers’

salaries and perks to create incentive for best practices in service.

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

9. Prominently publicize consequences of people’s use of such reporting mechanisms. Poor people will not come

forward to report poor service performance without concrete proof that it is worth their while to do so and that

it is risk free. Previous experiences have convinced them that seeking accountability is an exercise in futility.

7. 2. For Health Services

All of the above apply to Health Services. The following are additional specifi c recommendations:

1. Improve the transparency and fairness of procedures to identify the benefi ciaries of health cards or health

insurance (Kartu Sehat and Askes) using methods suggested in point 3 above.

2. Providing information can save lives. Galvanize the health service provision system to focus more on providing

life-saving information to empower the poor. Such information includes:

• Making benefi ts clear; sometimes the poor fail to use services because they are afraid of the expenses.

• Pregnancy danger signs that require immediate referral to a health center. The poor should not have to depend

on TBAs or other advisers to tell them when to take action.

• Comparison of ANC services at the TBA and the Puskesmas/Pustu in terms of life-protecting measures, such as

TT immunization, and better family-level preparation for potentially risky childbirths, e.g. counseling families to

be fi nancially and logistically prepared for emergency transportation to a health facility during labor when the

pregnancy has been identifi ed as a high-risk one.

• How to feed and care for infants when breastfeeding fails or during illness. (Information should go beyond

simple dispensing of drugs and oral rehydration salts).

3. Publicize measures available for the poor to make trained bidan desa’s services more aff ordable, e.g. Danareksa,

whereby the Puskesmas can reimburse the Bidan for her services to the poor. None of the poor men and women

in this study had heard about this.


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7. 3. For Education Services

To improve the quality of primary education in villages, a variety of issues need to be addressed: causes underlying

teacher absenteeism and performance; aff ordability and availability of text books; hidden, additional costs putting

education out of the reach of the poor; poor quality of school infrastructure.

1. Teacher absenteeism was consistently reported in rural schools; the cases were closely linked to the absence of

basic infrastructure services in the village such as clean water supply, sanitation and, to a lesser extent, electricity.

Parents said the teachers mostly hail from urban areas and are unwilling to live in the village when basic facilities

are lacking. Clean water and sanitation are important not just for teachers but also for students – for whom

learning key hygiene behaviors is not possible in the absence of water supply and sanitation.

2. The Ministry of Education (MOE) should adopt a policy to construct schools only with an assured sustainable

supply of clean water and locally appropriate sanitary toilets at a ratio of not more than 50 students per toilet.

The school health education unit (UKS) should design programs to promote the use of these facilities and key

hygiene practices, such as excreta disposal only in toilets and hand washing with soap after defecation and

before eating.

3. The MOE’s construction policies regarding primary schools should be reviewed for anomalies that impair quality

education. Currently, many primary schools are built with only two or three classrooms, which means that two

or three diff erent grades will always be combined for teaching, resulting in a poor learning experience.

4. Establish ways for parents to monitor and report on teacher absenteeism and performance to authorities who

are responsible for the teachers and their salaries. The use of teacher attendance registers maintained by school

PTAs and annual assessments of teacher performance by all parents of students by simple secret ballot voting

procedures could be linked to teachers’ salaries and increment payments. The Ministry of Education should be

more directly involved with parents in monitoring teacher absenteeism and enforcing sanctions.

5. Make textbooks available to all poor students. Some possible solutions: schools could purchase the books

and lend them to poor students (if necessary, a small, refundable deposit could be required). If students must

purchase books, the school should buy back books at the end of the academic year. Parents also suggested that

books cover two consecutive years of education, extending their life and cutting costs.

6. Registration fees at secondary schools deter enrollment of poor students. There seems to be no fi xed fees;

schools charge whatever they can. It is recommended that the government establish reasonable entry fees and

publicize them, e.g. a limit no higher than the equivalent of 4-5 days of the local minimum wages.

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



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transportation passes. Private sector transportation providers should be obliged to off er concessional rates

to students if they make use of public sector-provided incentives to promote entrepreneurship, e.g. loans at

concessional rates to buy public transport vehicles.

7. 4. For Clean Water and Sanitation Services

Policymakers need to wake up to the fact that the poor are paying exorbitant prices for clean water—as much

as 30 times utility rates. None of the 424 poor men and women consulted had piped water connections and so

did not benefi t from the heavily subsidized utility water that is enjoyed by the non-poor. With no access to public

water utilities they are forced to buy water from neighbors or independent providers. The rural poor depend on

groundwater, access to which is limited in the dry season.

About half the population in Indonesia, both the poor and the non-poor, continue to use water from shallow and

deep wells, even when they are connected to utility networks. Typically the well water is not potable in urban

areas.

At all eight sites the poor had almost no access to sanitation. The situation is representative of conditions across the

nation. In both rural and urban areas of the study people were using the nearest natural water body for defecation

purposes. The failure to provide basic sanitation solutions for the millions of the urban and rural poor is creating an

environmental disaster that impacts all Indonesians. Policymakers need to open their eyes to this little-recognized

public health disaster and deal with its roots.

Recommendations on Ways to Supply Clean Water to the Poor

1. In urban areas, assess the real costs of Small Scale Independent Water Providers (SSIPs) operation against

profi ts they make through use of PDAM water. Set non-negotiable ceilings on the price SSIPs may charge, so all

consumers pay the same in the city. SSIPs should not be allowed to enjoy subsidized PDAM rates while charging

exploitative rates to the poor.

2. Policies and regulations should help ensure competition among water providers, at least in urban areas where

multiplicity of providers is economically feasible. Publicize the ceiling rates to educate consumers and encourage

the poor to report violations. PDAMs should recognize the market share of the SSIPs and enter into formal

contracts with them for supply at lower-than consumers’ tariff rates, with the understanding that re-selling prices

will not exceed PDAM’s tariff rates for direct customers. PDAMs should monitor the rates charged by SSIPs to

consumers and sever supplies to SSIPs who charge exploitative rates.

3. Recognize that the urban poor are able and willing to pay fair rates for clean water. Poor customers are not an

obstacle to PDAMs charging tariff s that cover costs as well as reasonable profi t that can make PDAMs viable.


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The poor already pay the SSIPs a lot more than the actual production costs of PDAMs. The principal obstacles

to connecting the poor to PDAM networks, which need to be addressed creatively by service provision policies,

are: a) the high, one-time cash cost of connection that the poor typically cannot aff ord, and b) poor people’s lack

of tenurial status in their squatter settlements on public land – which at present does not allow them to seek a

legal water supply connection.

4. The rural poor were able to get reasonably clean ground water from protected dug wells or bore wells in

Java. Well water was not potable or suffi cient on the dry NTB island and in the swampy, riverine Kalimantan

village. Indonesia’s varied topographical and geo-hydrological conditions require various types of water supply

technologies that are geared to local conditions. A national approach to rural water supply should capitalize on

the rural population’s high demand for clean water services, and works with the poor to identify and develop

service options that meet local demands using technologies and water management arrangements that can be

sustained by the local population.

Recommendations to Improve Sanitation Services for the Poor

1. Scale up the application of approaches for rapid communitywide adoption of improved hygiene practices in

rural areas.11 Establish national policy and strategies for rural sanitation programs that will enable scaling up of

fi eld-tested best practices consistently across the country.

2. Scale up institutional capacity in local governments for promoting a range of locally appropriate low-cost

sanitation options so that sanitation is aff ordable by all. These could range from improved direct pit dry latrines

to more sophisticated off set-pit, composting, pour-fl ush and water-seal single or twin-pit latrines—all with

adaptations for cost-reduction using locally available materials.

3. Develop similar options for poor urban communities. A successful experiment in that direction was fi elded

through the SANIMAS12 project. The approach is currently being replicated by local governments. But because,

local governments and legislators do not yet understand the innovative process aspects of the SANIMAS

approach, its community mobilization and capacity building components are currently at a risk of being eroded.

Services created without adequate community capacity and ownership buildings are unlikely to be sustained.

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

To address this vacuum,

11 An example is the Community-Led Total Sanitation (CLTS) approach propagated through selected large scale RWSS programs, which builds com-

munitywide movements and social pressure for all households to be free of open defecation within short time periods. Field trial results in Lumajang,

Sumbawa, Muara Enim, Muaro Jambi, and Sambas districts have been promising. For more information see CLTS–related papers in issues of the

PERCIK newsletter on the GOI website: www.ampl.or.id

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

urban poor.



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• Urban policymakers must better understand the real costs of inaction and what makes for sustained services

as these are both key to progress on the urban sanitation front. Sector analyses studies and formative research

into how policymakers and opinion leaders think about sanitation in Indonesia are needed to develop

targeted advocacy campaigns to generate public pressure for improved sanitation services, and an enabling

environment for sanitation investments that can benefi t the poor.

• Devise innovative ways to catalyze high-level political commitment to improving sanitation services for the

urban poor. The ongoing failure to do so has resulted in a widespread urban health and environmental crisis in

Indonesia – both for the poor and the non-poor, yet the issue remains invisible and low priority for politicians

and leaders. Raising the political profi le of the sanitation agenda could include, for instance, cross-sectoral

analysis assessing the economic and human development costs to the nation from poor sanitation, linking

potable water resources and sanitation management with strategies for poverty reduction and economic

growth; organizing high-level regional conferences to periodically compare progress among neighboring

countries regarding their commitments to the MDGs for sanitation; raising consumer and voter awareness

regarding the impact on the entire population stemming from the absence of basic sanitation services for the

poor.

5. Equipping primary schools with clean water and basic sanitation facilities is considered one of the most cost-

eff ective investments for human development. However, provision of these services needs to be directed by

policies for sustained functioning and use, e.g. ratios of toilets to students not exceeding 1:50; mandatory

hygiene education curricula to accompany service provision; incentives and sanctions in allocation of

operational budgets to schools (BOS) linked to funtionality of school water and sanitation facilities.


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Annex 1: Study ToolsQualitative Research Sample and Sequence of Tools - Making Services Work for the Poor Study

INDICATIVE SEQUENCE AT EACH STUDY SITE

Respondents Research instrument Information targeted

1 Introductory meeting

with community

group

Mixed gender

and age groups,

possible presence of

community leader/s

Break into gender-

segregated groups.

• Introduction of researchers (important—

where are they from?)

• Explanation of purpose of meeting,

• Request for permission to research,

• Likely schedule of further discussions in the

community.

Welfare Classifi cation

Local Livelihoods pattern analysis—Have

both gender groups present results. Compare

and consolidate

Use available village/kelurahan map to identify

areas where most poor households are clustered

(using criteria from Welfare Classifi cation)

• Description of criteria locally

used to describe diff erent

levels of well being and

poverty

• Proportion of local

community “poor” by local

defi nitions.

• Pattern of major livelihood

activities, by gender.

• Proportion of average poor

hh’s. Income/earnings from

various sources.

2 Men, Women and

children met in

the course of the

walk through the

community

Transect walk (with copy of map, and

Environmental Healthwalk Observation

Checklist) to visit clusters of poor households,

explain purpose of visit, make appointments

for FGDs , observe environmental sanitation

conditions/ location of poor households vis-

à-vis public infrastructure facilities and health

and education service providers.

• Identifi cation of poor

households to contact for

setting up FGs

• Living environment and

facilities.


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3 Focus Groups with

men and women

from identifi ed

“poor”households

2 groups by gender,

each group with an

equal mix of 2 age

groups:

Young women

(15 - 30)

Young men (15-30)

Older women

(>30 – 50)

Older men (>30-50)

FGD: MAPPING SERVICE PROVIDERS

a. Venn diagramming for service providers in

general (See Guidelines provided)

b. Pocket voting: Mapping of local basic

service providers, for the selected Health,

Education, Water and Sanitation services.

(See Guidelines provided)

c. Ranking and scoring of options preferred

for H/E/WS services

OR

For the most used option in each category:

d. Benefi ts and Value for Cost perceptions

(See Guidelines provided)

e. Rating scales for satisfaction with the most

chosen option in each category —- criteria

used for judging quality (See Guidelines

provided)

f. If public services included among those

not used or little used, , probe for reasons,

perceived value for cost and quality.

_____________________________________

FGD: VOICE & CLIENT POWER ISSUES

With Discussion guide regarding poor

people’s experience, ideas for strengthening

accountability of service providers and

policymakers to the poor—

Possible Case Studies identifi ed for pursuing

further.

An overall mapping of the

service-providing agencies/

persons who are important to

poor women and men, as well

as those irrelevant or less useful

to them. Probing of reasons why

considered useful/not so.

• What service options are

available?

• Who is providing?

• Extent of usage of available

options

• Perceived costs of diff erent

options, in cash/kind/ time/

eff ort

• Who in the household

decides/chooses each type

of service option to use ?

• Actual expenditures incurred

to avail of services- in cash

and kind, time and eff ort

(daily/weekly/monthly/one

time)

Poor men and women’s

• rationale for choice ,

• Perception of value for cost

• Perception of what

constitutes quality service

__________________________

Poor people’s opinions and

experience re.exercising

client power, client voice,

accountability seeking by the

poor.



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Identifi ed poor

women /Men for

case studies

In-depth individual interviews to explore

case studies of failures of basic services,

(With reference questions for basic health serv-

ices failures)

Tracing events leading to

• Maternal death/disability from

childbirth,

• Stillbirth/neonatal death,

• Infant death,

• Under-5 death.

• Severe child malnutrition

• Girl/Boy of primary school age

never enrolled.

• Girl/Boy dropped out of pri-

mary school

Observations with checklists/standards for

• Puskesmas/ bidan/ dukun/ private doctor’s

outlet/service provision session.

• Primary school, Junior Secondary school/

class activity.

• Inspection of public and household latrines,

school sanitation and water facilities,

• Inspection of clean water sources, Water

storage and transportation facilities/

practices of water vendors,

• Water quality testing kit for drinking water in

poor homes

• Quality of selected types of

services provided by each

provider/obtained by the

poor.

• Condition of service facilities

Selected health/

education/water

and sanitation

service providers

Interviews with selected Service providers,

in each category

Providers’ views re:

• Quality of (identifi ed specifi c)

services provided

• Preferences of the poor.

• Obstacles to improving

services for the poor

• What can help the poor

obtain better services.


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The following participatory analysis tools13 were used to explore diff erent topics, mostly with men’s and

women’s groups separately.

Participatory Analysis Tools Description

Welfare Classifi cation* Tool to elicit local criteria by which people are classifi ed as poor, rich/

well off or in-between classes. This produced site- specifi c descriptions

of poverty, as well as the means to identify community households with

whom to engage in, for further research activities.

Social mapping* Activity to locate poor households in relation to other households,

infrastructure, and other basic services available in the community.

Health/environmental transect walk* Using the Social Map and a checklist for environmental observation,

researchers walked around the community to assess environmental,

health, and sanitation conditions, visit poorest clusters of households,

meet poor women and men, and set up appointments for group

discussions

Venn Diagramming This PRA tool was used to understand the institutions that are important

in poor people’s lives as well as those which are not relevant/unimportant

to them, and the poor people’s reasons for their assessments

Livelihoods analysis This PRA tool was used to rapidly map the major livelihoods –related

activities of poor women and men in the community, and the proportion

of total incomes derived from the various activities

Pocket Voting This was used to understand the choices available to the poor at each site

with respect to providers for diff erent types of services, and the extent to

which they were using each type

Rating scales* Graphic scales of standard length were used to elicit people’s satisfaction

levels with services. The two ends of the scale represented “No satisfaction

at all” and “Full satisfaction,” with mid-points and quarter points also

marked.

Benefi ts and Value for Cost* A quantitative participatory tool to obtain people’s assessment of the

extent to which their expectations are fulfi lled by the services available,

and the extent to which they think them to be worth the cost incurred to

obtain the services.

The sequence of tools was interspersed with focus group discussions covering several other aspects such as the

experiences of the poor in exercising voice in community decisions and in seeking accountability from service

providers. Site reports were produced by researchers for each site studied, in Indonesian, along with a documentation

of the results of each participatory analysis tool. Analysis was a collaborative exercise with most of the fi eld team

members. This consolidated report was written based on all of these outputs.

13 Fuller descriptions of the * marked MPA tools can be found in Sustainability Planning and Monitoring : A Guide to Methodology for Participatory

Assessment for Community-Driven Development Programs . Mukherjee, Nilanjana and Van wijk, Christine. Water and Sanitation Program, IRC

International water and Sanitation Centre and the World Bank. 2003..



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Annex 2: Village DescriptionsTable 2.1. Paminggir—Remote, Forestry-dependent Rural Community, South Kalimantan

Well being Indicator Rich (Kaya) In-between (Sederhana) Poor (Miskin)

Livelihood Own 10 fi sh ponds and

2-3 speedboats, successful

traders.

Fishers with 1 speedboat

and 2 fi sh ponds.

Wage laborers. No

fi shponds..

Diets Varied foods. Eat meat or

fi sh at every meal.

Can eat enough to fi ll

stomach.

Very simple meals,

sometimes quantity not

enough.

Clothes Many clothes, good

quality.

Enough for needs, but

average quality.

Few clothes, low quality.

Home ownership 20m x 8m size. High

quality timber (ulin) house,

tiled fl oor.

Medium quality timber

(Balangiran) house. Size

5-8m x 10m.

Low quality timber (katol)

house. Smaller than 5m

x 10m.

Livestock 30-40 buff aloes. 2-5 buff aloes. No livestock.

Health Services used Specialist doctors or city

hospital.

Health Center (Puskesmas). Traditional healer in

village/Pustu.

Income Rp.100,000/day. Between Rp.30,000-

Rp.100,000/day.

Rp.0-Rp.20,000/day.

Household assets All equipment, color TV

21” or bigger, refrigerator,

rice cooker, cupboard,

chairs + table of wood.

Some equipment, TV

14” or smaller. Cook with

kerosene, plastic or cane

chairs.

No TV. Cook with

fuelwood, 1 chair.

Contribution to Arisan

(saving + credit group)

Rp.50,000 / week. Rp.2,500-Rp.10,000/ week. Do not join arisan.

Proportion of

community households

16% 33% 51%

Table 2.2. Bajo Pulau - Island Fishing Community , West Nusa Tenggara

Well-being indicator Rich/able

(Aha mampu/kaya)

Middle/Suffi cient

(Cukuplah/Lung

satataba)

Poor

(Singsara/Tidak

mampu)

Livelihoods and livelihood

assets

Trade in lobster, pearls,

sea cucumber, marine

fi sh, own more than one

motorboat.

Sea fi shers, lobster and

pearl fi shers with own

motor boat.

Fishers with small sail

boat.

Income More than Rp.1 million/

day.

More than Rp.40,000/ day. Rp.10,000/ day.


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Children’s education High School. Primary – Secondary

School.

Do not complete primary

school.

Lighting facility Have generator. Get connection from

owners of generator.

Oil lamp.

Health service provider Specialist doctor in Bima

(city on mainland).

Puskesmas or private

doctor in Sape (town on

mainland).

TBA and traditional healer

in village.

Asset Stone-built house,

galvanized iron roofi ng,

on 12-20 stilts.

Tiled roof, plywood walls,

on 6-12 stilts.

Bamboo and thatch

roofed house, on 6 stilts.

Daily household

expenditure

Rp.50,000-Rp.100,000. Rp.25,000-Rp.40,000. Rp.8,000-Rp.9,000.

Daily expenditure to buy

water

Rp.10,000 (10 jerry cans x

35 liters).

Rp.5,000 (5 jerry cans x 35

liters).

Rp.1,000-Rp.2,000 (1-2

jerry cans x 35 liters).

Proportion of total

households

14% 42% 44%

Table 2.3. Alas Kokon - Rural, Dryland Farming Community, Madura, East Java

Well-being indicator Rich (Kaya) In-between (Sedang) Poor (Miskin)

House Permanent structure,

ceramic tile fl oor.

Simple house, self-

constructed.

Thatch house, dirt fl oor.

Livelihood Landowning farmers,

Government employees,

Fruit traders. Daily income

Rp.50,000 ++.

Laborers, some skilled. Unskilled laborers in

construction, agriculture,

transport.

Land ownership 2 or more hectares of

cropland.

0.5 to 2 hectares of

cropland.

No land owned. If owned,

only the land under the

house.

Livestock 3 or more cows or

buff aloes.

1-2 goats. Take care of

cattle owned by the rich.

Children education At the most complete

junior high school.

A few reach and complete

junior high school.

Only primary school. Many

drop out.

Health Services used Private doctor. Puskesmas and bidan desa. bidan desa or traditional

healer in village. If having

money, go to Puskesmas

(cost of transport).



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Water Supply Have own water storage

tank. Buy from water

truck.

• Dugwell, collect by

turn once/week.

• Buy from water truck

sometimes

• Bathe and wash in

river.

• Collect dugwell water

once/week by queuing

up, for cooking +

drinking

• Collect water for other

needs from river far

away. Many hours/

month used to collect

water.

Assets 4-wheel transport, TV,

tape recorder, refrigerator,

motorbike bought with

bank-loan.

Second-hand motorbike,

bough on credit.

No means of transport,

No TV.

Food Eat 3 times a day,

complete with meat or

fi sh and vegetables.

Simple meals, because

market is far.

Eat 2 times a day. Rice

with corn or cassava and a

little dried, salted fi sh.

Proportion of


9% 24% 67%

Table 2.4. Kertajaya – Irrigated Rice-Farming Rural Community, West Java

Well-being indicator Rich (Sugih)In-between

(Pertengahan)

Poor (Ora duwe,

melarat, miskin)

House • Permanent structure,

ceramic tiled/marble

fl oor, on 0.5 hectare

land, iron fencing;

• Have own bathroom

and sanitary toilet.

• Walls half cement half

wood/thatch;

• Simple bathroom and

pit latrine. House on

own land + 150m2;

• Furniture simple,

plastic.

• Bamboo thatch

house—leaks during

rain;

• Dirt fl oor;

• House built on

someone else’s land;

• Furniture wooden—

but- self-made.

Crop land ownership Up to 70 hectares—

stretching to next village.

1,000m2 – 0.5 hectare

only within the village.

No land owned.

Livelihood • Own rice huller/ shop/

tractor for renting/

business;

• Manage own

farmlands.

• Work in government

or private sector in

Jakarta;

• Use wage-laborers for

farming.

• Agricultural or

construction laborers

• Cart/rickshaw pullers

in Jakarta, Bekasi,

Pamanukan.


Voic

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f The

Poo

r

Transportation Car and motorbike. Motorbike. Bicycle.

Foods eaten daily Bread, milk, beef, chicken. Soybean cake, eggs

sometimes.

Rice, soybean cake,

kangkung (leafy

vegetable).

Children’s education Can go to college. Can complete high school. • Many children – all

cannot be educated;

• Some get primary

schooling, some never

enrolled.

Health Services Used • To private doctor in

Subang (district) or

Bandung (province

capital);

• Childbirth in hospital

• To Puskesmas Mantri or

doctor in village or in

Pamanukan (nearest

town);

• Childbirth with Bidan

desa

• If minor ailment – get

medicine from local

shop;

• If more serious – go to

Puskesmas with Kartu

Sehat or to Dukun (TBA).

Livestock Many goats – given to

poor people to maintain,

with sharing agreement

for off springs

Up to 10 goats Do now own. Take care of

goats of the rich.

Proportion of

Community households

13% 24% 63%

Table 2.5. Antasari—Urban Kelurahan , South Kalimantan

Well-being indicator Rich (Kaya) Middle (Sederhana) Poor (Miskin)

House Tiled roof, ceramic fl oor

tiles, cement and brick

walls.

Simpler home, galvanized

iron sheet roofi ng,

wooden board walls and

fl oor.

Thatched roof, thin board

walls, bamboo or board

fl oor.

Livelihood Trader, or government

employee level 3 or more.

Kiosk vendor, or

government employee

level 3 or lower.

Agricultural wage

laborers, construction

laborer, fi shers.

Mix with Mix only with the rich,

their own crowd.

Freely mix with both

richer and poorer than

themselves.

Avoid mixing with the

rich, feel embarrassed to.

Water Supply Drink bottled water.

Bathe, wash, cook in

water supplied by PDAM

connection.

Cook with and drink

PDAM water (own

connection). Wash +

bathe in dugwell water.

Drink and cook with

PDAM water (bought from

the rich). Bathe and wash

at dugwell or river.



Voic

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f The

Poo

r

Sanitation Sanitary toilet—more

than 1, built inside house.

Household toilet, but

some not sanitary, only

one per house.

• Public toilet

• In plastic bags and

throw out of house/

into river;

• No household facility.

Clothes and jewelry Silk, pure gold, Rolex

watch

Cotton, clothes. Gold-

plated jewelry

Ordinary clothes

Household assets 21” or bigger TV, high

quality furniture,

refrigerator.

Simple furniture – smaller

TV.

nothing

Food • Nutritious always

• Can eat at restaurants.

• Sometimes nutritious;

• Can eat at warungs

(roadside foodstalls)

Eat whatever is available

at home

Means of transport Car/motorbike Motorbike bought on

credit

Sometimes have bicycle.

Proportion of


19% 37% 44%

Table 2.6. Jatibaru—Urban Poor Kelurahan on the Outskirts of Bima, West Nusa Tenggara

Well-being Indicator Rich / Able (Ntau wara)Middle / Suffi cient

(Nohi ru’u)

Poor

(Ncoki mori)

Livelihoods and

Livelihood Assets

Civil servant, traders in

brick/stone, farmers.

Carpenter, horse cart

driver, seller/vendor,

wage laborers.

Wage laborers in agriculture,

brick/tile production,

collecting and selling wood

Income More than Rp.1,000,000/

month

Approx. Rp.10,000/day

not regular

Approx. Rp.5,000/day.

Children Education University High school Primary school/do not

complete primary school

Health Service provider Doctor. Traditional healer. Traditional healer in village.

Water and Sanitation

Services

Own latrine and dugwell

(water source)

Public dugwell, Open

defecation in river.

Public dugwell, Open

defecation in river.


Voic

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f The

Poo

r

Asset • own land (1 ha);

• permanent stone built

house with roof tile,

ceramic fl oor;

• Owner of cow/goat +

chicken (+ 10).

• Permanent (6-9

pillars) house, with

platform, cheap

rooftile, bamboo and

brick stone wall;

• Owner of goat,

chicken and duck;

• Own land (10 are)

Platform house (4 pillars),

cheap materials, bamboo

wall/fl oor.

Food Pattern 3 times per day, rice, fi sh,

vegetables, fruit.

2 times per day. Rice with

vegetables and small fi sh

(fresh) .

2 times per day. Rice with

salted dried fi sh, vegetables.

Proportion of

Community

households

18% 28% 54%

Table 2.7. Simokerto—Urban Low-Income Neighborhood and Squatters’ Settlement, Surabaya, East Java

Well-being indicator Well-off (orang mampu) In-between (sedang) Poor (tidak mampu)

House Permanent structure,

ceramic tiled fl oor, about

9m x 15m, Complete

facilities.

Simpler construction

about 5m x 8m.

Small 3m x 4m area,

Temporary structure of

ply-boards, tin roof, near

rail track. Live in parents’

house.

Water supply All have utility connection

– piped water. Drink, cook

+ bathe + wash with clean

water.

Some have utility

connections. Others buy

from vendor.

Dugwell water – poor

quality. Dries up in

summer. Forced to buy

expensive water from

vendor.

Sanitation Ceramic toilet pan, in

house sanitary toilet

Communal toilet. A few

have own simple toilet,

but not sanitary.

Open defecation in pits

on public land owned by

Railways corporation.

Livelihood Traders, shop owners,

permanent well-paid jobs,

salaried people.

Salaried people in public

or private sector.

Wage laborers, rickshaw

and cart-pullers, motor

garage workers, water

vendors. Unemployed

people.

Transportation Own car and motor bike. Own motorbike and cycle. Rickshaw or cart – but not

all have.



Voic

es O

f The

Poo

r

Income Above Rp.2 million/

month

Between Rp.300,000

– Rp.350,000/month.

Less than Rp.200,000/

month.

Children’s education High school and college Usually just high school. Pass primary school at the

most.

Health Services used Private hospital or

specialist private doctor

Puskesmas or public

hospital.

Traditional medicine

sellers (Jamu) or healers.

Sometimes go to

Puskesmas.

Electronic Goods owned 21” color TV, VCD player,

refrigerator.

14” TV, radio/tape player. None.

Proportion of


6% 22% 72%

Table 2.8. Soklat—Urban Poor Kelurahan in Subang, West Java

Well-being indicator Rich / Able (Benghar)Middle / Suffi cient

(Menegah/Cukup)Poor (Miskin)

Livelihoods and

Livelihood Assets

Doctor, civil servant,

trader, entrepreneur, own

shop, car repair shops.

Entrepreneur, car drivers,

teachers, share croppers.

Construction labor, farm

labor, service in a shop,

cart/rickshaw pullers

Daily household

expenditure

Big income. Enough to live on. Big expenditure but not

enough income.

Income More than Rp.3-4 million/

month. Can even be

Rp.50,000/ day

Rp.15,000-Rp.20,000/ day. Maximum Rp.10,000/ day.

Education University High school – Secondary

school.

Primary school only, or

do not even complete

primary school.

Health Service provider Doctor, private hospital,

mid wife in village.

Health Centre, bidan

desa, traditional healer in

village.

Massage, traditional

medicine. Buy drugs from

local kiosk.

House Clean, healthy, large

house, 2-3 storeys.

Ceramic fl oor, iron fencing.

Clean house, cement fl oor,

bamboo fence.

Poor quality house. Dirt

fl oor, roof tiles old, thatch

walls. No fence. Do not

own the land under the

house.


Voic

es O

f The

Poo

r

Asset Own refrigerator, sofa,

motor car, TV, luxurious

house.

Own TV, radio, bicycle,

simple chairs, rickshaw/

becak, own latrine, electric

pump for water.

• Old bicycle, small radio,

simple kitchen set;

• Nothing

Proportion of


20% 26% 54%

Annex 3

Table 3.1. Choice and Costs of Primary Education Services Reported by the Poor at 8 Sites SITES Certifi cate

(upon

completing

school)

Enrollment/

Registration/

Construction*

Uniforms Tuition

(monthly)

Books

(per year)

Shoes/Bag

(yearly)

Snacks

(daily)

RURAL

PAMINGGIR/

S.Kalimantan

(SDN)

7,500 10,000 - - - - -

BAJOPULAU/ NTB

(SDN)- - 140,000 / yr N.M. 60,000 55,000 1,000

ALAS KOKON/ Madura

(Madrasah Ibtidaiyah)- - 5-10,000** 10,000 - -

KERTAJAYA/ W.Java

(SDN)65,000 – 100,000

30,000 / yr7,000**

12,000

-18,000- 1,000

URBAN

ANTASARI / S.Kalimantan

– (SDN)7,500 -

75,000 /

3 yrs2,000** 15,000 1,000

JATIBARU: NTB

(SDN)5,000 100,000-

65,000 /

3 yrs- 20,000 35,000 -

SIMOKERTO: E.Java

(SDN)- 750,000- -

17,000** +

10,000 for

computer +

copybooks

80,000 - -

SOKLAT: W.Java

(SDN)100,000 100,000- 30,000/yr 10,000** 60,000 - -

* Payable in instalments throughout primary school period ** All reported that these fees are not being charged since September 2005

NOTE:

• SDN – Government- run Primary School

• Madrasah Ibtidaiyah – Community managed Islamic School

Husband and wife choose the school together at all sites



Voic

es O

f The

Poo

r

Figure 3.1. Benefi t and value perceptions for primary education services

Value for cost score

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

97.5

90 87.5 8892.5 91.4

65

80

100 100 100

26

95 94.3

62.5

82.2

0

50

100

PAMINGGIR BAJOPULAU ALASKOKON KERTAJAYA ANTASARI JATIBARU SIMOKERTO SOKLAT

SD Negeri SD Negeri Madrasah Ibtidaiyah SD Negeri SD Negeri SD Negeri SD Negeri SD Negeri

RURAL URBAN

rocSe

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

80

100

57.5

100

82.5

74

86

100100 100 100 100 100

74

80

63

0

50

100


SD Negeri SD Negeri Madrasah Ibtidaiyah SD Negeri SD Negeri SD Negeri SD Negeri SD Negeri

RURAL URBAN

rocSe


Notes:

SD Negeri = Government – run Primary School (grades 1 – 6)

Madrasah Ibtidaiyah = Religious school, also government – run (grades 1 – 6)


Voic

es O

f The

Poo

r

Figure 3.2. Satisfaction Ratings for Primary Education Providers

Paminggir

Bajopulau

Alas Kokon

Kertajaya

Antasari

Jatibaru

Simokerto

Soklat

Legends Women's Rating Men's Rating

SD Negeri

Madrasah Ibtidaiyah

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

50 27 88 5 100 80

50 0 100 60 70

100 0 25 50 75

0 100 50 75

0 100 50

60 0 100 50

25 0 100 50 80

0 100 50 75



Voic

es O

f The

Poo

r

Tabl

e 3.

2. C

osts

of s

econ

dary

scho

ol e

duca

tion

repo

rted

by

the

poor

at 8

stud

y sit

es

RURA

L

BAJO

PU

LAU

No

SMP

on th

e isl

and.

No

child

ren

cont

inue

. Mos

t boy

s dro

pout

eve

n fro

m S

D to

wor

k an

d ea

rn o

n bo

ats

KERT

AJA

YA O

nly

3 ch

ildre

n fro

m th

e vi

llage

go

to Ju

nior

Hig

h sc

hool

, out

side

villa

ge. T

hey

are

from

the

uppe

r cla

ss h

ouse

hold

s. Th

e en

try

fee

Rp.1

.5 m

illio

n is

an u

nthi

nkab

le

amou

nt fo

r poo

r hou

seho

lds

Gov

ernm

ent-

run

SMP

Neg

eri /

SLT

PM

adra

sah

Tasa

naw

iyah

/ Pes

antr

en

PAM

ING

GIR

* fre

e

ALA

S KO

KON

*Rp.

15,0

00 /

mon

th

(Com

mun

ity-

ente

rpri

se.

Onl

y 8

enro

lled

)

URB

AN

AN

TASA

RI*

Rp.1

00,0

00 /

yea

r, .b

ut.

all

stud

ents

re

ceiv

e

scho

lars

hip

JATI

BARU

Regi

stra

tion

Rp.1

20,0

00 +

Cons

truc

tion

fee.

Uni

form

45,

000/

yrTu

ition

Rp.

15,0

00/m

on.-f

ree

now

Boo

ks/s

hoes

/bag

20,

000-

112,

000

/yea

r

SIM

OKE

RTO

Cons

truc

tion

fee

Rp

600,

000

Uni

form

30,

000/

yr.

Tuiti

on R

p.38

-42,

000/

mon

. Fre

e no

w.

Book

s 80,

000/

yr

SOKL

ATCo

nstr

uctio

n fe

e R

p. 4

00,0

00

– 60

0,00

0

Uni

form

30,

000/

yrTu

ition

fees

25,

000/

mon

.Fre

e no

w. B

ooks

60,

000/

yr

Mad

rasa

h Ta

sana

wiy

ah –

Fun

ded

by D

ept.

of R

elig

ious

Aff a

irs ;

SMP

Neg

eri –

Fun

ded

by D

ept o

f Edu

catio

n &

Cultu

re. I

n vi

ew o

f the

dat

a fro

m W

elfa

re C

lass

ifi ca

tion

belo

w ,

Seco

ndar

y Sc

hool

see

ms t

o be

a se

rvic

e lit

tle u

sed

by th

e po

orW

elfa

re C

lass

ifi ca

tion

data

fro

m 8

site

s re

gard

ing

char

acte

rist

ics

of lo

cal

poor

in

term

s of

“ed

ucat

ion

of c

hild

ren”

:An

tasa

ri - “

Child

ren’

s edu

catio

n” n

ot m

entio

ned

amon

g re

port

ed c

hara

cter

istic

s of t

he p

oor

Jatib

aru

- “P

oor c

hild

ren

may

enr

oll i

n SD

(prim

ary

scho

ol) ,

ofte

n th

ey d

on’t

fi nish

SD

(prim

ary

scho

ol)”

Sim

oker

to

- “ T

he p

oor o

nly

pass

SD

/Mad

rasa

h Ib

tidai

yah.

Don

’t at

tend

SM

P/SL

TP (j

unio

r hig

h sc

hool

)”So

klat

- “

The

poo

r can

man

age

only

up

to S

D p

ass”

Pam

ingg

ir - “

Child

ren’

s edu

catio

n” n

ot in

clud

ed a

mon

g re

port

ed c

hara

cter

istic

s of t

he p

oor

Bajo

Pul

au

- “Ch

ildre

n of

the

poor

do

not e

ven

pass

SD

”Al

as K

okon

- j

ust r

each

SD

, not

pas

s, dr

op o

utKe

rtaj

aya

- chi

ldre

n no

t enr

olle

d in

scho

ol –

or o

nly

in S

D


Voic

es O

f The

Poo

r

Figure 3.3 Proportion of votes for provider of secondary school education services


63%

37%

SMP Negeri Madrasah Tsanawiyah/ Pesantren SMP Yayasan (private sector)

62%

37%

2%



Voic

es O

f The

Poo

r

Figure 3.4 Benefi t and value perceptions for secondary school education services

Secondary School Education Service Providers most used by the poor at 8 study sites: WOMEN's perception

93.390

92.5 91

80

87.593.3

10095 94

66

75

0

50

100


SMP Negeri - MadrasahTsanawiyah

- MadrasahTsanawiyah

SMP Negeri SMP Negeri SMP Negeri

RURAL URBAN

rocSe

e Value for cost score

loohcs oN

loohcs oN

Secondary School Education Service Providers most used bythe poor at 8 study sites: MEN's perception

90

67.5

93.3

74

92.586.67

100

87.5

100

74

62.568.3

0

50

100


SMP Negeri - MadrasahTsanawiyah

- MadrasahTsanawiyah

SMP Negeri SMP Negeri SMP Negeri

RURAL URBAN


oN

cslooh

oN

c sloo h

rocSe

Notes:

SMP Negeri = Government run junior high school (grades 6 – 8 or 7 – 9)

Madrasah Tsanawiyah = Religious school, run by government (Department of Religious Aff airs), grades 6 – 8)


Voic

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f The

Poo

r

Figure 3.5 Satisfaction ratings for secondary school education providers

Paminggir

Bajopulau

Alas Kokon

Kertajaya

Antasari

Jatibaru

Simokerto

Soklat

Legends Women's Ratings Men's Ratings

SMP Negeri

MTSn

SMP Yayasan


50 0 100

0 100 50

60 0 100 50

0 100 50 75

50 40 90 2 100 10

100 0 25 50 75 45

0 100 50 90 10

25 0 100 50 55



Voic

es O

f The

Poo

r

Tabl

e 3.

3. C

hoic

e an

d Co

sts o

f AN

C Se

rvic

es U

sed

by th

e Po

or a

t 8 S

tudy

Site

s

RURA

L SI

TES

PAM

ING

GIR

/ S.

Kalim

anta

nBA

JOPU

LAU

/ N

TBA

LAS

KOKO

N /

Mad

ura

KERT

AJA

YA/ W

.Jav

a

Mos

t use

dBi

dan

Kam

pung

(TBA

)

Rp.3

-5,0

00 /

visit

Sand

o (T

BA)

Free

or 1

kg ri

ce

Duk

un (T

BA)

Rp.5

,000

/ exa

min

atio

n

bida

n de

sa, p

ract

icin

g at

hom

e

in th

e ev

enin

gs

Rp.2

5,00

0 (in

cl.R

p.10

,000

fo

r

tran

spor

t)

In c

ompa

rison

with

oth

er

choi

ce a

vaila

ble

If bi

dan

desa

ava

ilabl

e in

PUS

TU,

then

at P

USTU

Rp.3

-5,0

00/ e

xam

inat

ion

bida

n de

sa –

but n

ever

ava

ilabl

e

bida

n de

sa

• Rp

.15,

000/

exa

min

atio

n

Rp.2

5,00

0/ h

ome

visit

Duk

un (T

BA)

2-5

kg ri

ce

URB

AN

SIT

ES

AN

TARA

SARI

/ S.

Kalim

anta

nJA

TIBA

RU /

NTB

SIM

OKE

RTO

/ E.

Java

SOKL

AT /

W.J

ava

Mos

t use

dPu

skes

mas

Rp.3

,000

/visi

t

• Sa

ndo

(TBA

) acc

ordi

ng to

wom

en

Rp

.3-5

,000

+ 1

cup

rice

• Pu

skes

mas

– a

cc.to

Men

.

Rp.3

,000

/visi

t

Pust

u/ P

uske

smas

Rp.1

1,00

0 (in

clud

es R

p.6,

000

for

tran

spor

t)

• Pu

skes

mas

Rp.

12,5

00 (i

ncl.

Rp.1

0,00

0 fo

r tra

nspo

rt)

bida

n de

sa p

ract

ising

at

hom

e

Rp.3

5,00

0 (in

cl.

Rp.1

0,00

0 fo

r

tran

spor

t)

In c

ompa

rison

with

oth

er

choi

ce a

vaila

ble

Bida

n Ka

mpu

ng (T

BA)

Rp.5

,000

/ exa

min

atio

n

bida

n de

sa

Rp.1

0-15

,000

Duk

un (T

BA)

Rp.3

,000

Para

ji (T

BA)

Rp.

3-5,

000

NO

TE:

Wom

en g

ener

ally

cho

ose

the

ANC

serv

ice

prov

ider

. M

en a

re in

volv

ed in

dec

idin

g w

ith w

omen

if se

ekin

g AN

C se

rvic

es c

osts

cas

h m

ore

than

Rp.

10,

000.


Voic

es O

f The

Poo

r

Figure 3.6 Benefi t and Value Perceptions for ANC Service Providers

ANC service providersmost used by the poor at 8 study sites: WOMEN's perception

100

62.5

72

46.67

93.390

70

95

100

95

100

20

100 100

74

100

0

50

100


Bidan kampung

TBA

Sando (TBA) Dukun beranak

TBA

Bidan Puskesmas Puskesmas Sando

TBA

Bidan Puskesmas Puskesmas

RURAL URBAN

rocSe



9094

72.570

100

84 82 8283.33

94

100

76.67

100

84

100

82

0

50

100


Bidan kampung

TBA

Sando (TBA) Dukun beranak

TBA

Bidan Puskesmas Puskesmas Puskesmas Bidan Puskesmas Puskesmas

RURAL URBAN

rocSe


Notes:

Dukun beranak/paraji/bidan kampung/sando = traditional birth attendant

Puskesmas = Primary Health Centre

Bidan Puskesmas = trained midwife at Primary Health Centre, government employee



Voic

es O

f The

Poo

r

Figure 3.7 Proportion of votes for choice of provider for Childbirth Assistance Services


76%

14%

8% 2%

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

Puskesmas Public hospital

64%

15%

18%

3%


Voic

es O

f The

Poo

r

Tabl

e 3.

4. C

ost o

f Chi

ldbi

rth

Assis

tanc

e Se

rvic

es U

sed

by th

e Po

or a

t 8 S

tudy

Site

s

RURA

L SI

TES

PAM

ING

GIR

/ S.

Kalim

anta

nBA

JOPU

LAU

/ N

TBA

LAS

KOKO

N /

Mad

ura

KERT

AJA

YA/ W

.Jav

a

Mos

t use

dBi

dan

Kam

pung

(TBA

)

Rp.2

5,00

0 -5

0,00

0 +

Ric

e 2k

g +

2 co

conu

ts

Sand

o (T

BA)

Rp.2

5,00

0 -5

0,00

0 +

rice

2kg

+ 1

coco

nut.

Afte

r 3 d

ays p

ost b

irth

anot

her

Rp.2

0,00

0, ri

ce+

coco

nut

Duk

un (T

BA)

Rp.5

0,00

0

Para

ji (T

BA)

Rp.5

0,00

0 -1

00,0

00 +

20k

g ric

e

Com

pare

d to

oth

er

avai

labl

e ch

oice

bida

n de

sa

Rp.2

00,0

00-4

00,0

00

No

othe

r op

tion.

bida

n de

sa n

ever

ava

ilabl

e w

hen

need

ed

bida

n de

sa

Rp.1

50,0

00 -2

00,0

00

bida

n de

sa

Rp.3

00,0

00 -4

00,0

00 +

Rp.1

0,00

0 fo

r tra

nspo

rt

URB

AN

SIT

ES

AN

TARA

SARI

/ S.

Kalim

anta

nJA

TIBA

RU /

NTB

SIM

OKE

RTO

/ E.

Java

SOKL

AT /

W.J

ava

Mos

t use

dBi

dan

Kam

pung

(TBA

)

Rp.5

0,00

0 -2

00,0

00 +

rice

,

coco

nut,

suga

r

Duk

un (T

BA)

Rp.1

0,00

0 +

1kg

rice

bida

n de

sa

Ro.3

00,0

00 +

Rp.

20,0

00 fo

r

tran

spor

t

Para

ji (T

BA)

Rp.5

0,00

0 -1

00,0

00 o

r

Rp.5

0,00

0 +

5 k

g ric

e

Com

pare

d to

oth

er

avai

labl

e ch

oice

bida

n de

sa

Rp.2

50,0

00 -5

00,0

00

depe

ndin

g on

leng

th +

com

plex

ity o

f lab

or

bida

n de

sa

Rp.3

00,0

00 -4

00,0

00

Duk

un (T

BA)

Not

use

d an

y m

ore

bida

n de

sa

Rp.3

00,0

00 -4

00,0

00

NO

TE: A

ccor

ding

to m

en, t

he h

usba

nd c

hoos

es th

e se

rvic

e pr

ovid

er, f

or c

hild

birt

h.

Acc

ordi

ng to

wom

en, h

usba

nd a

nd w

ife d

ecid

e to

geth

er.



Voic

es O

f The

Poo

r

Figure 3.8 Satisfaction Ratings for Childbirth Assistance Providers

Paminggir

Bajopulau

Alas Kokon

Kertajaya

Antasari

Jatibaru

Simokerto

Soklat

Legends Women's Ratings Men's Ratings

Public hospital

Bidan Desa

Posyandu

TBA

Puskesmas


50 0 100 10 70 90

45 75 0 100 50

50 30 3 70 100

100 0 45 50 75

0 100 50 25

0 100 50

0 100 50

0 100 50 75


Voic

es O

f The

Poo

r

Figure 3.9 Benefi t and Value Perceptions for Childbirth Assistance Providers

most used by the poor at 8 study sites: WOMEN's Perception

97

90

75

98 97.5

91.67

82

68.75

100 100 100 98 100 100

54

68.7

0

50

100


Bidan kampung Sando (TBA) Dukun beranak Paraji Bidan kampung Sando (TBA) Bidan Puskesmas Paraji

RURAL URBAN

rocSe



96.67

8588

9590

84

76

96.67100 100 100 100 100

84

90

100

0

50

100


Bidan kampung Sando (TBA) Dukun beranak Paraji Bidan kampung Puskesmas Puskesmas Paraji

RURAL URBAN

rocSe


Notes:

Dukun beranak/paraji/bidan kampung/sando = traditional birth attendant


Bidan desa = trained midwife, resident in village, government employee




Voic

es O

f The

Poo

r

Figure 3.10 Proportion of votes for provider of Infant Health Care Services (2M – 5Y)


9%

8%

3%

17%

35%

23%

2% 4%

Sando/Bidan Kampung/Paraji/Dukun Bayi Sando/Dukun berobat

Dokter (Private practice) Pustu


Mantri (Paramedic) Public hospital

Posyandu

4%5%

6%

17%

21%

36%

7%2% 3%

Figure 3.11 Proportion of votes for provider of Infant Health Care Services (0 - 2M)


12%

2%

5%

17%

33%

30%

0.5%

Sando/Bidan Kampung/Paraji/Dukun Bayi Sando/Dukun berobat

Dokter (Private practice) Pustu


Public hospital Posyandu

20%

2%

17%

28%

30%

1% 2%


Voic

es O

f The

Poo

r

Tabl

e 3.

5. C

osts

of O

ne-t

ime

Use

of C

urat

ive

Care

Ser

vice

s Mos

t Use

d by

the

Poor

for T

heir

Child

ren

unde

r Fiv

e

RURA

L SI

TES

PUSK

ESM

ASPU

STU

TBA

/Tra

ditio

nal H

eale

rbi

dan

desa

PAM

ING

GIR

S.K

alim

anta

nRp

.5,0

00Rp

.5,0

00 -1

0,00

0

(if P

USTU

pro

vide

rs n

ot a

vaila

ble,

as

happ

ens f

requ

ently

)

BAJO

PULA

U

NTB

Free

(dur

ing

fi rst

44

days

the

baby

is

deem

ed to

bel

ong

to th

e TB

A w

ho

deliv

ered

it)

If TB

A ca

nnot

cur

e, n

ext c

hoic

e is

Man

tri

at R

p.20

-50,

000

ALAS

KOKO

N M

adur

aRp

.15,

000

(if n

ot c

ured

then

seco

nd c

hoic

e M

antr

i or K

yai

at R

p.25

000-

50,0

00)

KERT

AJA

YA W

.Java

Rp.1

5,00

0 +

Rp.

10,0

00 fo

r

tran

spor

t

URB

AN

SIT

ES

ANTA

SARI

S.K

alim

anta

nRp

.3,0

00

JATI

BARU

/ N

TBRp

.3,0

00 +

Rp.

3,00

0 fo

r tra

nspo

rt

SIM

OKE

RTO

E.Ja

vaRp

.5,0

00 +

Rp.

6,00

0

for t

rans

port

SOKL

AT

W.Ja

va

Rp.2

,500

(if t

his d

oes n

ot c

ure

then

next

to B

idan

- at

Rp.

25-3

0,00

0.

If Bi

dan

can’

t hel

p th

en p

rivat

e

doct

or a

t Rp.

40-7

0,00

0 +

cos

t of

med

icin

es)



Voic

es O

f The

Poo

r

Figure 3.12 Benefi t and Value Perceptions for Curative Services for Infants (0-2 months)

Met and Value for Cost forInfant (0 - 2 months old) Health Care Service Providers most used

by the poor at 8 study sites

92.5

76.67

64

85 8590

66

76

90

100

94

50

92.596.67

60

72

0

50

100


Puskesmaspembantu

Sando Bidan desa Bidan Puskesmas Puskesmas Puskesmas Puskesmaspembantu

Puskesmas

RURAL URBAN

rocSe


Infant (0 - 2 months old) Health Care Service Providers most used bythe poor at 8 study sites

90

100

80

90

100

84

94 92.5

70

100

92.590

100

84

100 100

0

50

100


Puskesmaspembantu

Sando Bidan desa Puskesmas Puskesmas Puskesmas Puskesmaspembantu

Puskesmas

RURAL URBAN

rocSe


Notes:

Pustu (Puskesmas pembantu) = Sub-primary Health Centre (outreach facility)


Bidan desa = trained midwife, resident in village, government employee


Sando = Traditional healer


Voic

es O

f The

Poo

r

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

Paminggir

Bajo Pulau

Alas Kokon

Kertajaya

Antasari

Jatibaru

Simokerto

Soklat

Legends Women’s Rating Men’s Rating

Public hospital

Bidan Desa

Posyandu

Pustu

TBA

Puskesmas

Private doctor

Mantri

Trad. healer


0

0

0

10 0

0

0

0



Voic

es O

f The

Poo

r

Figure 3.14 Benefi t and Value Perceptions for Water Supply Option Used

Met and Value for Cost forWater Services most used by the poor at 8 study sites

100

8590

93.390

78

92 93.396.67

100 100 100

63.3

100

85

100

0

50

100


River Vendor from otherisland

Protected publicdugwell

Public handpump Buy PDAM waterfrom neighbor

Unprotected dugwell Vendor resellingPDAM water

Unprotected publicdugwell

RURAL URBAN

rocS

e


xpectation Met and Value for Cost forWater Services most used by the poor at 8 study sites

90 90

100

83

100

81.67

93.3

100

93.3

100 100

86

100 100

91.67

100

0

50

100


River Vendor from otherisland

Protected publicdugwell

Public handpump Buy PDAM waterfrom neighbor

Unprotected dugwell Vendor resellingPDAM water

Unprotected publicdugwell

RURAL URBAN

rocS

e



Voic

es O

f The

Poo

r

Figure 3.15 Satisfaction ratings for water supply options

Paminggir

Bajo Pulou

Alas Kokon

Kertajaya

Antasari

Jatibaru

Simokerto

Soklat

Legend Women’s Rating Men’s Rating

River

Dug welll

Dugwell with pump (sanyo)

Borewell with pump (sanyo)

Hand pump

Utility water resold by neighborVendor-sold PDAM / borewell water

Score 0 = No satisfaction at allScore 100 = Full satisfaction

0 63 90 1 00

0 100

0 25

0 10 100

0 100

0 100

0 50 75 100

0 85 100

40

10050

8050

50

60

50

30



Voic

es O

f The

Poo

r

Figure 3.16 Benefi t and value perceptions for sanitation facilities

Met and Value for Cost forSanitation Facility (Latrine) most used by the poor at 8 study sites

100

56.67

76

96.5

88

70

100

83.380

9093.5

100

48

100

0

50

100


River (opendefecation)

Beach (opendefecation)

Unimproved dry pithousehold latrine



(drop)


Field (opendefecation)

Shared householdlatrine

RURAL URBAN

rocSe


Sanitation Facility (Latrine) most used by the poor at 8 study sites

92.5 94

70

100

88

36

100

90

100

76

100 100

44

100

0

50

100



Beach (opendefecation)




(drop)


Field (opendefecation)

Shared householdlatrine

RURAL URBAN

rocSe



Voic

es O

f The

Poo

r

Figure 3.17 Satisfaction ratings for sanitation facilities

Paminggir

Bajo Pulou

Alas Kokon

Kertajaya

Antasari

Jatibaru

Simokerto

Soklat

Legend Women’s Rating Men’s Rating

Shared household latrine

Public toilet

Open pit latrine at home

Open defecation in backyard

River/sea

Pond

Simple pits, away from home

Score 0 = No satisfaction at allScore 100 = Full satisfaction

0 80 90 100

0 100

0 25

0 5 100

0 10 25 100

0 50 75 100

0 50 75 100

0 30 85 100

25

10050

45 50

25

50 75

Documents

Voices of the Poor - World Banksiteresources.worldbank.org/INTINDONESIA/Resources/Publication/... · Voices of the Poor is based upon fi eld work done by a team consisting of Nyoman