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PUBLIC HEALTH COMMUNICATIONS CAMPAIGN IN INDONESIA:
LESSON LEARNED AND THE WAY FORWARD
The World Bank Indonesia Health, Nutrition and Population Team
April 2013
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TABLE OF CONTENTS PART 1: Overview ................................................................................................................................................... 3
Country Overview .............................................................................................................................................. 3
MDGs and Stunting in Indonesia ........................................................................................................................ 3
Part 2: Review of Evidence & Past Experiences ...................................................................................................... 6
Communication in Nutrition .............................................................................................................................. 6
International Experiences .................................................................................................................................. 7
Peru – My Life in Centimeters........................................................................................................................ 7
Multi-Region (Bangladesh, Ethiopia, Vietnam) – Alive and Thrive ................................................................ 8
Health Communication Campaigns in Indonesia ............................................................................................... 9
The Context .................................................................................................................................................... 9
Challenges to Campaign Implementation .................................................................................................... 11
Lessons Learned ............................................................................................................................................... 18
The Way Forward: A Campaign Approach ............................................................................................................ 22
Pre-Campaign ................................................................................................................................................... 22
Phase I: Year I ................................................................................................................................................... 22
Phase II: Year II – IV .......................................................................................................................................... 25
Phase III: End of Year IV and Beyond................................................................................................................ 26
Annex I. Case Studies ............................................................................................................................................ 28
Annex II. List of Indonesian Programs Reviewed .................................................................................................. 45
Annex III. List of Interviewees ............................................................................................................................... 59
Annex IV. Steps in Communication for Behavior Change ..................................................................................... 60
Annex V. Sample of Terms of Reference for the Formative Research ................................................................. 61
Detailed research designs will be proposed by the research contractor and finalized in collaboration with the
the relevant stakeholders. .................................................................................................................................... 62
Submission of draft reports as deemed necessary and the production of a final report. ........................... 62
Formulation and implementation of appropriate dissemination strategy. ................................................. 62
A final report document in … copies with detailed findings in English and Bahasa Indonesia. ................... 63
Output .................................................................................................................................................................. 63
Duration ................................................................................................................................................................ 63
Preparation ........................................................................................................................................................... 63
Week 1-2............................................................................................................................................................... 63
Submission of inception report with refined methodology ................................................................................. 63
Week 3 .................................................................................................................................................................. 63
Training and Field work ........................................................................................................................................ 63
Week 4-14............................................................................................................................................................. 63
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Analysis and preparation of initial draft report .................................................................................................... 63
Week 15-18........................................................................................................................................................... 63
Submission of initial draft report .......................................................................................................................... 63
Week 19 ................................................................................................................................................................ 63
Workshop to present and discuss findings with all stakeholders ......................................................................... 64
Week 20 ................................................................................................................................................................ 64
Finalization of report ............................................................................................................................................ 64
Week 21-23........................................................................................................................................................... 64
Submission and presentation of final report ........................................................................................................ 64
Week 24 ................................................................................................................................................................ 64
Annex VI. Sample of Terms of Reference for the Communication Agency .......................................................... 65
Annex VII. Sample of Invitation for Advertising Agency ....................................................................................... 68
Annex VIII. Template of Creative Brief ................................................................................................................. 69
Additional DocumentS .......................................................................................................................................... 70
Document 1 – Stakeholders Consultant REPORT ................................................................................................. 71
4. THE FINDINGS .................................................................................................................................................. 72
A. Lessons Learned – best practices from past campaigns .............................................................................. 72
Document 2 – Campaign Steps ............................................................................................................................. 80
Document 3 – feedback ........................................................................................................................................ 86
Document 4 - communication campaign plan ...................................................................................................... 99
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Project Background
One of the key challenges currently facing the health sector in Indonesia is that of chronic child malnutrition. While
Indonesia is on-track to attaining the nutrition-related MDG relating to reducing the prevalence of underweight among
children less than five (current estimates place the prevalence rate around 18 percent), reducing the prevalence of
other malnutrition-related indicators such as early childhood stunting remains a challenge.1 Currently, 35.6 percent of
Indonesian children, or one out of every three children under five in Indonesia are shorter than the standard height for
their age.2 Stunting in the first two years of life can lead to irreversible damage including shorter adult height, lower
schooling attainment, reduced adult income, decreased offspring birthweight and increased incidence of morbidity in
later life. There is also wide variation in the prevalence of stunting within Indonesia. According to Riskesdas 2010 data,
16 out of 33 provinces in Indonesia had a rate of stunting among children 0-5 years old that exceeded the national
average. This problem is also compounded in rural areas where it is estimated that 42 percent of households had
stunted children, a level comparable to those observed in poorer sub-Saharan African countries.3 Continued problems
with sanitation, open defecation, and inadequate access to clean water compound the problems associated with early
childhood stunting in Indonesia.
In an effort to address the persistent challenge of childhood stunting in the country the Government of Indonesia,
through support received from the Millennium Challenge Corporation, will seek to undertake a new initiative aimed at
supporting demand and supply interventions aimed at reducing stunting for children 0-2 years old, and based on the
community development experience gained under the PNPM Generasi Sehat dan Cerdas program.
The Community Based Health and Nutrition to Reduce Stunting Project will seek to improve maternal and child
nutrition, increase rates of breastfeeding and improving sanitation standards, all of which have found to have a positive
effect on decreasing stunting rates in developing countries. For these reasons, this project will includes proposed
activities aimed at specific improvements in the following areas:
i. Improve maternal nutrition and decreased incidence of children born less than 2500 grams
ii. Increase rates of exclusive breastfeeding among children 0-6 months old
iii. Improve understanding and application of weaning and complementary feeding practices among lactating
and mothers of children 7-24 months old
iv. Improve sanitation conditions and household hygiene behaviors
v. Communities and service providers enter into mutually-agreed upon contracts aimed at ensuring a
connection between stunting prevention services and community activities
As part of these project proposal development activities, The World Bank has been tasked with assisting the
Government of Indonesia, under the design of the Community Based Health and Nutrition to Reduce Stunting Project,
to develop an appropriate approach for a national stunting awareness campaign aimed at increasing public awareness
of early childhood stunting as a national nutrition issue.
Process & Purpose of this Situation Analysis
The objective of the situational analysis is to assist the Government of Indonesia in determining communications needs
and outcomes for a national campaign to promote greater awareness around the issue of childhood stunting. In order
to accurately capture of picture of past experiences and propose a multi-tier communications strategy that would be
aligned with the objectives of this project the authors employed a mix of desk research on national and international
experiences with nutrition and health-related campaigns as well as interviews with key project stakeholders. These
interviews included government officials, representatives of international agencies, donor partners, and private sector
contractors involved in the development and execution of those campaigns and individual consultants with expertise in
1 Riset Kesehatan Dasar (Riskesdas) 2010 estimates gizi buruk (4.9 percent); gizi kurang (13.0 percent) 2 Riset Kesehatan Dasar (Riskesdas) 2010 3 IFLS 2007. IFLS data is likely to underestimate the problem, especially in rural areas, as it did not include the poorest provinces of the country.
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development communications in general and behavior change communications in particular. A full list of interviewees
included as part of Annex 1 of this document.
Information gathered during the assessment of past campaigns and stakeholder interviews is central to developing
appropriate background materials that would enable future bidders for implementation to have access to a
comprehensive landscape of health and nutrition communications efforts in Indonesia and abroad. This landscape is
also critical in ensuring that bidders are able to develop strong bids for campaign implementation that both adequately
address the overarching goals of the project while incorporate lessons learned from past nutrition/health campaigns.
This report is organized in three key areas. Part 1 provides a country and issue overview which discusses the growing
issue of childhood stunting in Indonesia. Part 2 includes a review of past health and nutrition campaigns undertaken in
Indonesia, and internationally where campaigns in Peru, Vietnam, Ethiopia and Bangladesh have had success in
socializing ideas around stunting and encouraging greater participation by father’s in health-seeking activities. The
campaign case studies and Health Communications Project Matrix included in Annex 1 and Annex II of this report
provides further insights provided by 30 past health projects in Indonesia and Timor Leste (1988 to present) and
includes additional information on campaign objectives, lessons learned, budgets and campaign strategies. To capture
the broadest possible scope of initiatives and lessons learned, the case studies range from well-documented,
pioneering long term investments in family planning efforts Blue Circle (Lingkaran Biru), to highly localized disease
eradication efforts like those conducted under the auspices of SISKES on remote Alor island, NTT, where long-term
sustainability was ensured by the investment in building supportive and effective relationships with local government
and the Dinas Kesehatan. Of particular relevance to a future stunting campaign was Helen Keller International’s
National Vitamin A Supplementation Program collaboration with the Ministry of Health.
Part 2 of this report also builds on stakeholder consultations and the review of past campaigns and offers background,
challenges and lessons learned for the implementation of a new campaign to address stunting. Additional information
from these consultations can also be found in the Stakeholder Consultation Report and accompanying powerpoint
presentation included in Document 1 of this report.
Finally, Part 3 of this document proposes a way forward for beginning to design and implement critical steps in
campaign planning, design, implementation and evaluation. As part of this section Terms of Reference needed to
develop a competitive Request for Proposals (RFP) for international bidding are available for both Formative Research
and Campaign Implementation in Annex V and Annex VI of this report. These Terms of Reference also contain
additional information such as contract assignment overview, purpose, expected outcomes, benchmarks, qualifications
and selection criteria, all of which can be modified based on additional project details that may become available.
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PART 1: OVERVIEW
COUNTRY OVERVIEW
Established in 1945, the Republic of Indonesia is the fourth most populous country on earth with a population of
approximately 240 million people. An archipelagic state of more than 17,000 islands, it extends roughly 3,000 km from
Aceh Province on the cusp of Andaman Sea, to Merauke in the Papua Province, just 320 km from the northeastern tip
of Australia. Indonesia is divided into 33 provinces, 497 districts / municipalities and 6,598 sub-districts and 75,638
villages. Act no. 22 on Regional Government was implemented in 2010, giving autonomy to districts to conduct their
own planning and budgeting system in their respective regions, including in the health sector.
Diversity has always been a challenge for Indonesia. There are more than 300 languages and a variety of ethnic groups
in this former Dutch colony, the largest of which are Javanese (40%), Sundanese (15%) and Madurese (3%), and one
third of the population fits into the category of “other”. The national language, Bahasa Indonesia, is taught in all schools
and is widely spoken and read across the country particularly by people under the age of 40. It is also the main printed
language in Indonesia. Javanese, Sundanese, Acehnese, Batak, Minangkabau, Betawi, Banjar and Bugis round out the
main linguistic groups, but local dialects are widely spoken, particularly in the remote regions of the archipelago.
MDGS AND STUNTING IN INDONESIA
The Indonesian economy has made a remarkable turn-around in the 15 years since the Asian Economic Crisis and is on
track to meet many of its Millennium Development Goals (MDGs) by 2015. Under-five mortality rates have plummeted
from 97/1,000 live births to 44/1,000 between 1989 and 2007. Indonesia has also already met and surpassed projected
reductions in the number of under-five underweight children, shown by a drop from 50% to 17.90% between 1989 and
2010 and the government is optimistic it will reach its 2015 target of 11.9%4.
While Indonesia is on-track to attaining the nutrition-related MDGs of reducing the prevalence of underweight among
children less than five year old, reducing the prevalence of early childhood stunting remains a challenge. Currently,
Indonesia is the fifth country with the largest numbers of stunting in under-five children with an estimated 7,688,000
children suffering from this condition5 and a national prevalence of 35.6%6 or one out of every three under-five children
in Indonesia are shorter than the standard height for their age.
There is also a wide variation in the prevalence of stunting within Indonesia, ranging from 58.4% in East Nusa Tenggara
to 22.5% in DI Yogyakarta. However, all of the provinces in Indonesia still have a stunting prevalence above 20%, the
World Health Organization’s (WHO) standard of public health problem. This problem is also compounded in rural areas
where it is estimated that 42% of households have stunted children, a level comparable to those observed in poorer
sub-Saharan African countries7. Continued problems with sanitation, open defecation, and inadequate access to clean
water added to the complexity of the problems associated with early childhood stunting in Indonesia.
4 Report on the Achievements of Millennium Development Goals in Indonesia, Ministry of National Development Planning / National Development Planning Agency (2011) http://www.undp.or.id/pubs/docs/ (accessed on Dec 14, 2012) 5 Tracking the Progress of Child and Maternal Nutrition, op.cit. 6 Riset Kesehatan Dasar 2010, Badan Penelitian dan Pengembangan Kesehatan – Kementerian Kesehatan RI (2010) 7 IFLS 2007. IFLS data is likely to underestimate the problem, especially in rural areas, as it did not include the poorest provinces of the country
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Graphic 1. Provincial Stunting Rates (Riskesdas, 2010)
However, it is worth noting that stunting does not ‘cause’ health conditions, it is the underlying factors that cause
stunting that are also likely to impair children’s physical and intellectual growth. It begins with poor nutrition standards
during pregnancy, inadequate pre-natal care and poor sanitation resulting in low birth weights and early stunting.
These early handicaps are exacerbated by poor breastfeeding practices, such as early weaning, poverty and diets
lacking essential micronutrients as well as environmental issues, like inadequate sanitation that contribute to
infections, disease and continued nutrient losses. This ‘perfect storm’ of complex issues has serious downstream
impacts on children’s physical and emotional development.
While rates of stunting are much higher in eastern Indonesia, the greatest numbers of stunted children are found in
West Java, East Java, Central Java and North Sumatera. More than half of all cases nationally can be found in these four
provinces8.
Graphic 2. USAID Indonesia Nutrition Assessment for 2010
Adding to the existing challenge is the growing problem of double burden of malnutrition, which refers to the
coexistence of under-nutrition and over-nutrition of macronutrients as well as micronutrients, across the life course of
the same population. In Indonesia the issue of over-nutrition (or gemuk) has gone largely unaddressed by most
packages of nutrition interventions, which are still only focusing on alleviating severe child under-nutrition. However,
there is also evidence that the incidence of obesity and stunting is growing among young children in Indonesia. This
relationship is also known as the Double Burden of Malnutrition, by which early nutrition deficiencies, lead to
micronutrient malabsorption and higher incidence of Non-Communicable Diseases (NCDs) later on in life.
8 USAID Indonesia Nutrition Assessment for 2010 (USAID, March 2010)
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Evidence from Riskesdas 2010 shows that national rates of gemuk are steadily increasing among children under 5 years
of age, and particularly among poorer populations in Indonesia’s outer islands where children face elevated levels of
stunting and wasting. USAID Indonesia Nutrition Assessment for 2010 notes:
In addition to the problem of under-nutrition, the numbers of overweight children and adults are increasing.
According to a recent national survey, among adults 19.1 percent are overweight or obese. This double burden
[of under- and overweight] is caused by inadequate prenatal, infant, and young child nutrition followed by
exposure to high-fat, energy-dense, micronutritent-poor foods and lack of physical activity (Haddad, Alderman,
and Appleton, 2003). Poor maternal nutrition, stunting, urbanization, and dietary changes are all contributing
to a transition to chronic nutritional and health problems.
While nutritional and environmental contributors to stunting have and are being addressed in Indonesia, the issue has
yet to be addressed in a systemic and holistic manner. Consequently, there is very little understanding about what
stunting is, from the highest policy-making levels of government to communities whose social and economic well-being
is being undermined by chronic, multi-generational and preventable conditions. As stated by Professor Soekirman, a
leading nutritional expert in Indonesia,
“… information on stunting as a serious nutritional problem is not yet accepted by society, including the
medical experts. The appropriate meaning of stunting as [a reflection of] chronic under-nutrition is only
understood by a limited number of Indonesian nutritionists and public health personnel.”
A challenge of designing a campaign specifically targeting childhood stunting is the issue of limited knowledge and
perceptions about it among the broader population. In fact, there is no actual term in Bahasa Indonesia that accurately
evokes the nuances of the term stunting. ‘Pendek’, the term currently used to signify stunting, translate to ‘short’ in
English and does not associate this issue with any long-term nutritional or developmental effects.
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PART 2: REVIEW OF EVIDENCE & PAST EXPERIENCES
COMMUNICATION IN NUTRITION
A cost-effectiveness study conducted on the Nutrition Communication and Behavior Change Component (NCBC) of the
first World Bank project Indonesia for community nutrition showed that successful nutrition communication activities (
which provided educational inputs only) led to an improvement in the nutritional status of 40% of children, and cost a
mere .15% of the national budget. Indeed, effectively implemented nutrition communication efforts are one of the
most cost-effective methods for creating an environment to improve practices by addressing barriers regarding
knowledge and practices on infant and young child feeding. It is not surprising then that a clear communication strategy
and implementation plan is a critical first step in beginning the process of bringing about sustainable changes in
generating demand for infant and young child feeding services and setting the stage where individual behavior change
is supported by community members, basic health and social services as well as effective policies in several sectors.
A review of existing meta-analysis and other relevant literature has shown that the average health campaign affects the
intervention community by about 5 percentage points, and nutrition campaign for fruit and vegetable consumption, fat
intake and breastfeeding have been slightly more successful on average than for other health topics. It can be
concluded that nutrition campaigns that pay attention to specific behavioral goals of the intervention, target
populations, communication activities and channels, message content and presentation, and techniques for feedback
and evaluation should be able to change nutrition behaviors9.
It is important to note that communication can play distinctive roles in promoting healthy behavior. Some
communication is tailored by and for mothers or their influencers (promoting individual, family, and community
actions), some for communities motivating improvements in community conditions for nutritional well-being, some for
health staff or other program implementers (improving services and counseling), and some for policy makers (advocacy
to support the program)10.
In general, development communication has three major components:
- Behavior Change Communications employs a variety of communications strategies and tactics to promote
behavior change, improved knowledge, attitudes, practices and the participation of the target audiences.
Success is heavily dependent on a clear understanding of local conditions in target areas.
- Social Mobilization organizes local institutions and networks including traditional, religious and business
leaders, and civil society to create ‘demand’ for the project.
- Advocacy mobilizes leadership to support the goals of the project.
Successfully moving from A to Z through a communications project requires a solid, evidence-based strategy. There are
numerous analytical models from which a development communications strategy may stem from, but it is noted that
they bear many similarities, particularly the need for an investment in research and planning, a strategy development
process that includes pre-testing of messages and materials, an on-going monitoring mechanism to allow for
adjustments and fine-tuning throughout the life of the project, and a rigorous evaluation period after the campaign.
The ‘Communication for Behavior Change in Nutrition Project’ (World Bank, 1999) outlines the basic steps in planning
and implementing a communication program:
1. Situation analysis and review of existing information to learn what key information is already available and
what new research is required.
9 Snyder, Health communication campaigns and their impact on behavior, J Nutr Educ Behavior, 2007; 39:S32-S40 10 Favin and Griffiths, Communication for Behavior Change in Nutrition Projects: A Guide for World Bank Task Managers, The World Bank, 1999
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2. Formative research on consumers’, health workers’, and/or policy makers’ perceptions and practices is
intended to gain insights into the reasons people have for particular behaviors related to the nutrition or
health problems the program will address.
3. Strategy formulation and initial decisions made on the key behaviors, target audiences, a draft message
strategy for each, anticipated media, and plans for the development, pretesting and productions of the
materials.
4. Project execution includes stakeholder meetings, finalizing the message strategy, completing and producing all
materials and training staff in communication and other needed skills, and conducting a baseline. It is launched
and then monitored during the course of the project.
5. Evaluation is conducted to assess the impact and guide decisions on continuing or expanding activities.
Complete steps in communication for behavior changes including the estimated range of time can be found in Annex III.
INTERNATIONAL EXPERIENCES
PERU – MY LIFE IN CENTIMETERS
Picture 1. My Life in Centimeters
In 2007, the World Bank produced My Future in My First Centimeters11, a 15-min video for an established Scaling Up
Nutrition effort that compares the physical and cognitive growth of children in rural and underserved areas of Peru
where many rural children are malnourished, stunted, and developmentally delayed. It chronicles the stories of
children in two Andean villages, contrasting the dramatic growth and developmental differences between under-fives
who are receiving suitable nutritional support on one hand with those who are not. The video was intended as a
practical tool for parents and health workers, which conveys the complexity of accountability in nutrition in easily
digestible messages. A key element, and one that will be of significant importance in the Indonesian context where
awareness and understanding about stunting, is that the video asserts unequivocally that every child has the same
potential for linear growth, regardless of their ethnicity, nationality, and socioeconomic status.
Aside from misconceptions about the nature of stunting, a key element of the challenge facing any campaign that is
common to both Peru and Indonesia is complacency. There is a danger that community caregivers, health workers, and
11 The video can be accessed on YouTube: http://www.youtube.com/watch?v=mJieb2Xgt9U
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high-level policymakers will remain complacent when they are not confronted daily by the measurable consequences of
under-nutrition.
A community monitoring program encouraging mothers to track their children’s growth has significantly improved child
heath in the target communities. It was found that mothers who receive monthly updates and advice on their child’s
progress are more likely to provide a proper diet, which allows for the children to grow stronger, physically and
cognitively. It was first introduced in Peru, but was such a success that it was culturally adapted and translated for use
in five other countries in the region, namely Ecuador, Guatemala, Honduras, Mexico and Nicaragua where it is regularly
shown in health center waiting rooms. More than ten thousand copies were distributed to the 31 states of Mexico
alone. Shorter versions were presented to policy-makers at high-level meetings. All videos are available on YouTube,
where collectively they have been viewed over 40,000 times. The same video replicated within the Indonesian context
would be a valuable educational and awareness-raising tool.
MULTI-REGION (BANGLADESH, ETHIOPIA, VIETNAM) – ALIVE AND THRIVE
As part of its six-year initiative (2009-2014) to improve Infant and Young Child Nutrition (IYCN) by increasing rates of
exclusive breastfeeding in Bangladesh, Ethiopia, and Viet Nam, the Alive and Thrive (A&T) has launched several efforts
to engage fathers more actively in child care that could serve as useful examples and approaches for a stunting
campaign in Indonesia.
A&T complements its program activities with demand-side interventions using marketing principles of social and
behavior change communication. As stated in its website (www.aliveandthrive.org), these principles include: 1) a
situation analysis with formative assessments, 2) identification of priority audiences and appropriate communication
channels, 3) development and testing of messages and materials, and 4) a limited number of core messages.
This communications strategy targets both individual behaviors and social norms. It aims at shaping demand by
delivering messages consistently and frequently through multiple behavior change channels to reach primary and
secondary audiences. It engages the media and various organizations to promote messages.
The essential components of the social and behavior change communication approach include:
a. Media audit and formative research to identify critical feeding problems, constraints, and opportunities.
b. Harmonization of messages to various agencies, organizations, and sectors were conducted to ensure that
messages are aligned.
c. Interpersonal communications to provide ongoing encouragement and support during home visits, group
discussions, mother support groups, informal encounters in the community, and counseling sessions at health
centers.
d. Community mobilization to engage groups in IYCF promotion and support, generate demand for services,
facilitate dissemination, and establish recommended practices as the social norm.
e. Audience-oriented and appealing media including TV and radio spots and programs, newspaper articles,
village loudspeaker network, video vans, client materials, literacy booklets, certificates, and branding materials
to reinforce messages, remind audiences of the desired behaviors, recognize achievement, and increase the
perceived “value” of IYCF services.
f. Measurement, learning, and evaluation to assess the impact of the media and factors influencing trial and
adoption of recommended practices among caregivers of infants and young children.
9
The Ethiopian program developed “7 Excellent Feeding Actions” with simple, useful messages such as: “Fathers, for
your child to be healthy, smart and strong, it’s your job to make sure that your baby has special foods added to his
porridge”. Furthermore, actions included monitoring frequency of feeding, promotion of exclusive breast feeding and
practical suggestions for farmers in regard to nutrition such as retaining a few eggs for home use rather than selling all
at the market.
This is supported by interpersonal counseling tools that elaborate these ‘actions’. Supporting materials like the “child
nutrition card” encourages the whole family to track a child’s progress together. Families that adopt these actions are
awarded certificates which they post on their doors to serve as models for the community. Outreach efforts were
supported by mass media community messaging including radio and TV public service announcements (PSAs), a radio
drama serial and film and music video.
The Hanoi School of Public Health was awarded an A&T grant to create and evaluate a program to help fathers support
their wives’ efforts to breastfeed exclusively. They employed humor in sloganeering, rescheduled counseling sessions to
coincide with monthly immunization days when fathers were more likely to attend, created a “TV-reality-show-style”
competition ("Who loves their wives and children most?") designed to make it “seem manly to speak up for
breastfeeding”.
Picture 2. Campaign Theme of Alive and Thrive Program in Vietnam
A key element was identifying “do-able” actions and simple messages that could be reinforced during one-on-one and
group counseling sessions and in the supporting collaterals like posters, pamphlets and PSAs. Actions included
encouraging husbands to do chores that their wives would normally do to allow time to breastfeed, being supportive
and accompanying her on visits to the doctor12.
HEALTH COMMUNICATION CAMPAIGNS IN INDONESIA
THE CONTEXT Indonesia has deep roots in health sector communications with initiatives dating back to the 1960s particularly in the
areas of family planning, maternal and neo-natal health, immunization and vitamin supplementation. However, there
are significant challenges to accessing their usefulness as a reference in a future stunting campaign due to a variety of
reasons. The results of a global review of health sector social and behavior change interventions prepared by the Johns
Hopkins Bloomberg School of Public Health, on behalf of the Bill and Melinda Gates Foundation and released in 2011,
concluded that while nutrition was the second most represented area in the literature from developed countries it was
the least represented category in developing countries. Consequently the pool of knowledge related to nutrition is
limited even when the net is widely cast.
Indonesia has benefited from numerous donor-funded campaigns across a vast spectrum of broadly defined health
sectors with varied success. These include initiatives related, among others, to infant and young child nutrition, family
planning, vitamin-A supplementation, hand washing, avian influenza, HIV/AIDs, tuberculosis, open defecation. These
campaigns have typically been conducted as small elements of broader technical projects.
12 Sample of brochure:http://www.aliveandthrive.org/mwg-internal/de5fs23hu73ds/progress?id=61WnHKz69/
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A detailed mapping of communications materials for IYCN in Indonesia conducted on behalf of GAIN in 2010-2011
provides a comprehensive overview of materials and programs the GoI has launched through the Center for Health
Promotions, Indonesian Ministry of Health (MoH). All outreach efforts by the Directorate General of Nutrition, Child
and Maternal Health, MoH, are meant to be coordinated with the Centre for Health Promotions, the clearinghouse for
the development of materials and approaches. While this is generally the case, 2012 also saw the launch of a modest
effort related to the “1000 Days” program in selected provinces that was developed in direct collaboration with a
private sector firm.
Picture 3. Illustration of The “Healthy Four / Perfect Five” Concept
In some cases, the government’s efforts to develop messaging and slogans have been extremely successful. One
example is the slogan of the National Population and Family Planning Board’s (BKKBN) successful Suharto-era campaign
to lower the birthrate in Indonesia: Dua Anak Cukup (Two Children are Enough). Another is Empat Sehat/Lima
Sempurna (Healthy Four/Perfect Five), the widely-disseminated national milk-centric nutritional index. These are two
examples of slogans that have, for better or worse, become part of the national consciousness, recalled and recycled in
internet messages, radio jingles and comedy skits.
“The Blue Circle [campaign] is one of the most successful campaigns ever. Perhaps we could learn to replicate
its strategy in mobilizing all elements from the military to the village leaders” (Staff of Ministry of Health).
“Four healthy, five perfect has been a successful slogan, but we need to fix the content of this slogan”.
“Four Healthy, Five Perfect” – based on a national campaign in the 1950s - is arguably the most notable nutrition
message to date. The campaign was very successful and the outdated slogan still stays in the mind of Indonesians
despite efforts to introduce the more appropriate “balanced nutrition” paradigm, which incorporate messages in
regard to balanced portions of different food groups.
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Picture 4. Illustration of Balanced Nutrition Cone resembles nasi tumpeng,
a traditional Javanese yellow rice cone served during celebrations
The new tumpeng gizi seimbang (balanced nutrition cone) illustration above also integrates representations of other
healthy lifestyles practices like hand washing, exercise and weight management into the “serving plate” base.
Other nutrition-focused promotional efforts developed by the MoH in partnership with national and international
organizations encompass promotion of exclusive feeding of mother’s breast milk (Air Susu Ibu – ASI - Eksklusif)
through the first six months of life, micronutrient advocacy including Vitamin-A (see annex for case studies), the use of
iodized salt, and a micronutrient powder called Taburia. Current efforts in these areas are often tied into broader
‘umbrella’ healthy lifestyles promotions that have been a central element of the ministry’s public information mandate
for several years.
CHALLENGES TO CAMPAIGN IMPLEMENTATION
There are several issues worth noting based on the results of interviews with the stakeholders and other informants, as
well as the documents reviewed:
I. The importance of formative research
This assessment found little evidence of a systematic approach to compiling data or developing methodologies that are
likely to affect behavior change among target audiences. Staff at the Centre for Health Promotions acknowledged some
familiarity with the importance of and theoretical basis for conducting knowledge, attitudes and practices assessments,
for example, but said lack of resources, expertise and a lack of time prevented these types of activities from being
undertaken. The 2010 assessment of the government’s approaches reached many of the same conclusions:
Not many researches are focused on nutrition‐related knowledge, attitude and practices (KAP), so it is highly
unlikely that real behavior data are actually used in the development of communication materials. One of the
reasons of this might be because the studies are very small in scope, thus not very useful in developing a
nation‐wide communication campaign. Another reason might be the fact that behavior change communication
has not been widely understood and implemented13.
13 Mapping of Communication Materials on Infant and Young Child Nutrition in Indonesia (GAIN, 2011)
12
Many of the stakeholders interviewed for this situation analysis identified formative research as a vital component of
the communication campaign:
“A formative research is crucial to be implemented prior to the campaign, when we will be questioned why we
do all these things, we need to have an evidence-based documentation to support our activities” (Staff of
Ministry of Health).
“Formative research is crucially needed before conducting the overall health communication campaign. We
need to figure out the trends and have an evidence-based documentation on the perceptions, attitudes and
practices of mothers in relation to their children’s growth. What is important for them? Their intelligence? Their
physical appearance? Their height? Their weight? I totally agree with having a formative research before
conducting the campaign” (Staff of Ministry of Health).
II. Quantity and Quality of Information
Perhaps nowhere is the difficulty of improving infant and young child feeding practices better highlighted than in the
case of breastfeeding. Despite decades of investment by the national government and foreign donors, and incremental
improvements in performance, Indonesia ranked 37th (out of 40) with a score of 57.5/150 according to the 2012 World
Breast-Feeding Trend Initiatives (WBTi) report. By contrast, neighboring Thailand and Phillipines both scored 75.514,
placing them 29th on the list.
The WBTi report identifies information and community support as key elements lacking from Indonesia’s approach. It
gives a failing grade to the MoH’s efforts to educate Indonesian citizens about the IYCN. In the category of “mother
support” and community outreach it only scored a three out of ten. It also assesses information support on IYCN as two
out of ten, 50th out of the 51 countries surveyed (2012), partly due to the absence of a national strategy as well as the
lack of a national IEC campaign or program using electronic, print media and activities to channel messages on IYCF in
the last 12 months.
Picture 5. Sample of communication materials with complex information
produced by an international NGO
14 http://worldbreastfeedingtrends.org/
13
One of the lessons learned from past campaigns is that lack of focus has always been a challenge. The abundance of
information related to nutrition and its complexity had not always been successfully managed, resulting in confusing
messages that may not seem relevant to the public. Lack of behavior data and information regarding nutrition due to
the absence of formative research, might have also made it especially difficult to pick and choose issues that are most
strategic in bringing about change in nutrition behaviors.
III. A Comprehensive Communication Strategy
Though Indonesia scored the maximum point of two in the WBTi report for technical accuracy of IEC messages, the
absence of a national IEC strategy relating to infant and young child feeding is a major setback. This is also evident in
the various communication materials on IYCF reviewed for the situation analysis. There was no clear guideline
regarding the content and design of IYCF communication tools produced by MoH or any other organization, resulting in
inconsistencies both in messaging and visual presentation of communication tools produced for the general public. The
lack of consistent “branding” made each of the messages competes with each other instead of supporting one another
to amplify its affect.
“There is no use to have themes change every year, with no clear direction on what to achieve at the end.”
(Staff of Ministry of Health)
“It is time for the Ministry of Health and Government of Indonesia to have an official 5 year grand design
strategy for communication, fully endorsed, with proper formative research and monitoring evaluation.” (Staff
of Ministry of Health)
Further assessment and dialogue are needed to decide on the priority/ies of the campaign, because a clear, simple but
relevant message seemed to work best in previous campaigns. Issues that came up during the interviews were in
relation to:
- Regular visits to the Posyandu (integrated health services post)
- Nutrition during pregnancy
- Exclusive breastfeeding
- Consumption of Fe Tablets
- Complementary feeding
- Male Participation
- Micronutrient powder
Several suggestions regarding the general direction of the campaigns were also collected during the stakeholders
meetings.
“I completely disagree with the use of the word ‘stunting’ for this campaign. It is not a word that can be easily
understood by mothers. Perhaps we could use the word ‘malnutrition’ instead and link it to child rights” (Staff
of Ministry of Health)
“It is the best time to use social media in our strategy” (Staff of Ministry of Health)
Past campaigns have successfully used popular culture to disseminate messages on nutrition. The practice of utilizing
local celebrities as ambassadors have shown favorable results both in the commercial and non-commercial settings.
Though further research is needed, some stakeholders have shown interest in exploring this further.
“My dream is to take advantage of the mass media, collaborate with the private sector and high rating soap
operas such as ‘Tukang Bubur Naik Haji’ and insert [messages] about ‘taburia’ or exclusive breastfeeding within
several episodes that are broadcasted and viewed by millions of viewers.” (Staff of Ministry of Health)
14
Many stakeholders interviewed suggested that the campaign also target policy makers, because there were signals
indicating that the issue of stunting was not yet a priority. Linking the communication campaign on stunting with other
current programs such as Scale Up Nutrition (SUN) and Healthy Behaviors (PHBS) may also be a useful strategy to
increase the visibility of the issue.
To improve IYCN practices, significant investment needs to be made to implement a comprehensive strategy on IYCF.
The WBTi recommends a “comprehensive strategy that covered National (sic) Coverage, using multi-media with
adequate budget.”15
IV. Multi-stakeholder Involvement and Coordination
One of the issues identified during the development of the situation analysis is the need to involve various stakeholders
to implement the communication strategy. Staffs of Ministry of Health identified several key players:
- Ministry of Health
- The National Agency of Food and Drug Control (BPOM)
- Ministry of Internal Affairs
- Ministry of Communication and Information Technology
- Ministry of Agriculture
- National Planning Board (Bappenas)
“The key players for the ad hoc team should be divided by its specific roles and expertise. Stunting issues should
be managed by the Ministry of Health and The National Agency of Food and Drug Control (BPOM). The BPOM
definitely plays a significant role in the team, specifically in relation to food safety. Moreover, the Ministry of
Internal Affairs will play a significant role in conducting advocacy to all levels. Ministry of Communication and
Information Technology is in charge in disseminating information, while Ministry of Agriculture plays a
significant role in food security and poverty reduction. Last but not least would be Bappenas that coordinates
everything.”(Staff from Ministry of Health)
Past experiences have proven that multi-stakeholders involvement presents a real challenge in coordination. Therefore,
measures must be taken to ensure that the decision making process throughout the communication campaign can still
be conducted in a prompt and constructive manner.
V. The Challenge of Decentralization
An ambitious and historic decentralization process over the past 15 years has seen power devolve from the central
government to the provinces and districts. The knockdown effects of this on the delivery of health services are beyond
the consideration of this assessment, yet its impacts in practical terms has been acknowledged by all practitioners.
Government studies show that at the beginning of this decade there was a wide variation between districts in
efficiency of health resource use and that most district systems operated at sub-optimal levels. Even though
there have been significant increases in public funds for health, recent studies show that not only has little
changed, but also that there is no relationship between public spending on health at the district level and
health system outputs. During this period there has also been a failure of leadership, political as well as
bureaucratic, in the health sector.16
The mobilization of political support at the local level is a feature of successful campaigns of the decentralization era
identified in past experiences. From the perspective of communications and outreach efforts at the sub-national level,
15 Status of Policy and Programmes in Infant and Young Child Feeding in 40 Countries; Gupta, Holla, Dadhich, Suri, Trejos and Chenetsa: Health Policy
and Planning 2012; 1-20; University of Oxford Press in assn. with London School of Hygiene and Tropical Medicine 16 Heywood and Choi: Health system performance at the district level in Indonesia after decentralization. BMC International Health and Human Rights 2010 20:3
15
the decentralization process is both good and bad news. District heads (bupati), elected officials, health officers etc.
now enjoy considerable discretion in identifying local needs and supporting national health initiatives like stunting
campaigns. The flip side of the equation is that the weakening of the central government’s role in implementation and
oversight translates into project partners having less leverage at the sub-national level. The shift of trend calls for an
advocacy strategy to ensure that various levels of government as well as other relevant stakeholders are on-board and
ready to support the campaign.
VI. Integration of Communication Campaign to the Health Care System & Community Outreach
The network of 260,000 posyandu, integrated health services posts that formed the backbone of an ambitious Suharto-
era community health program, is the entry point for the delivery of basic health services to under-fives in Indonesia.
Infant weight and height monitoring, vaccinations, health and nutritional education for mothers and other health
services relevant to a stunting campaign are conducted at the village/kampung level by the local posyandu supported
by community volunteers called health cadres (kader).
The posyandu can serve as an excellent platform for information dissemination. Experienced international actors like
UNICEF and Save the Children have and continue to invest in supporting the operations of posyandu in areas where
projects are being implemented, as do smaller national NGOs like the Ibu Foundation. At their most functional, they
have evolved into infant learning centers, recreational spaces and reading rooms, etc.
However, their functionality varies widely across the country. Large parts of the network have never recovered from
the political and social turmoil of the late 1990s. By some estimates, half of all posyandu are no longer operational due
to a lack of funding, political will, training for kaders and a gradual increase in the number and availability of local
community clinics preferred by wealthier and/or better educated parents.
Services at community-based clinics, known as posyandu, are declining. “Posyandu provide an early warning
detection mechanism for problems relating to pregnancy,” said Yusma Sari, a coordinator at the Kartika
Sukarno Foundation (KSF), a local NGO that supports community clinics on the islands of Sumatra, Java and
Bali. “They’re really important for identifying malnourishment, along with checking the weight of pregnant
women and issuing them with vitamins,” she said. “Posyandu are dying. The government [used to send]
midwives to give… medical expertise, but this support has decreased. Also, posyandu used to hold sessions for
pregnant women every day, but now it’s once a month.” 17
Currently, training module for health cadres and health workers on IYCF is already available. The module includes
various messages on nutrition such as exclusive breastfeeding and complementary feeding. The module has been
utilized to train cadres at the community level and must not be perceived as a separate activity from the
communication campaign. Community outreach is a part of the communication strategy that needs to be implemented
consistently.
Structural and administrative changes associated with decentralization have in some cases severed the links between
posyandu and the puskesmas originally intended to provide support and trainings to the volunteer staff. The
consequence of this uneven service delivery platform is that an assessment of posyandu in target areas should form
part of the planning stage of a stunting campaign and efforts made to address varying capacities through targeted
trainings of kaders.
In addition to the posyandu and puskesmas, other health care service providers – both government and privately
owned – are potential channels that needed to be explored and utilized further.
VII. Monitoring and Evaluation
17 http://www.irinnews.org/printreport.aspx?reportid=95781
16
In-depth results-based assessments are few and far between; the focus of post-mortems looking at communication
efforts tend to track quantitative variables such as the volumes of materials delivered, people trained and workshops
held rather than the cumulative impact of the works. If evaluations are available, they often use health indicators to
measure success instead of communication indicators. Therefore, it is difficult to pinpoint whether success or failure
was the result of the program intervention in general or the communication activities. As one development
communications specialist said:
“Often evaluations of communications-related elements of these campaigns focus on programmatic indicators
rather than campaign/communications indicators which make assessments of these campaigns somewhat
difficult if not impossible.”
A detailed mapping of communications materials for IYCN in Indonesia conducted on behalf of GAIN in 2010-2011
reached the same conclusions:
“Many informants could not provide data, samples or reports on the communication materials that were
produced for past programs, making it difficult to review methods utilized by these organizations to develop
behavior change strategy, the quality of the materials, or the end result. The absence of evaluation reports for
some of the programs made it especially difficult to assess whether the communication strategy was effective
or not.”
A staff from the Ministry of Health provided an example of such a case during an in depth interview,
“There was an interesting experience back in the 80s with The Manoff Group that worked out well. However,
when we scaled it up, we had to deal with many challenges and ended up simply distributing posters. There
was no evaluation, thus we had no clue on our strengths and weaknesses.”
The absence of evaluation to date, prompted a stakeholder to comment,
“Evaluation [of the communication program] is a must! Unfortunately we didn’t apply it in the past.”
VIII. Level of Effort and Financial Investment
A national communication campaign is a massive undertaking, requiring capable human resources to manage the
process. Although the bulk of the work will be implemented by third party contractors, it must be supervised and
monitored constantly throughout the whole process. Past experiences have shown that a team of experienced
communication specialists are needed to ensure smooth development and implementation of the strategy. The
absence of technical experts in the process often resulted in ineffective campaign management, which in turn impacted
effectiveness and efficiency. Therefore, getting the right people to manage the campaign is crucial.
Financial resources to carry out a communication campaign vary greatly, depending on the level of visibility, scope, and
penetration desired. As an example, one of the candidates for governorship in Jakarta invested close to US$ 700.000 in
2012 to get himself elected into office18, while UNICEF launched a US$ 3.5 million national avian influenza campaign to
tackle the outbreak in 200719 in addition to Government of Indonesia’s undisclosed budget for the same campaign.
Awareness efforts on avian influenza included a mass media campaign, events and community outreach activities,
including production of AI kits. It is estimated that between US$ 60.000 – US$ 100.000 was invested for a 6-month
campaign in a single district during the peak of the outbreak. The formative research preceding the campaign cost
approximately US$30.000 for data collection in one district.
18 http://megapolitan.kompas.com/read/2012/08/03/15402886/ 19 http://www.unicef.org/indonesia/id/media_7124.html
17
During the in-depth interview with different departments within the Ministry of Health, a potential combined budget of
approximately US$ 550,000 might be available for IYCF communication campaign. The challenge was to deliver the
work within a short time span with limited funds that need to be disbursed within a particular period, making it difficult
to plan the spending accordingly. Consequently, campaigns are often implemented based on a fund disbursement
schedule instead of the needs of a comprehensive strategy.
IX. Working with Third Party Contractors
While government capacity in health communications varies, the past decade has seen the emergence of a robust
public relations and marketing industry in Indonesia. The professional landscape in Indonesia has mirrored the
country’s gradual emergence from the chaos of the late 1990s. Fifteen years ago there were very few creative agencies
in Indonesia. Today the sector is booming and highly fueled by an explosion in television advertising directed at the re-
emerging middle class.
The major global public relations players are now well represented either through partnerships with local start-ups,
acquisition of established firms or opening of bespoke offices. Several large independent Indonesian firms are thriving
and a host of smaller, spin-off operations headed by managers and creative directors attempting to parley their
professional experience with industry leaders into creating “boutique” operations have sprung up. All are heavily
concentrated in Jakarta.
It is likely that as part of efforts to plan a stunting communications campaign, the project will need to engage local or
internationally based creative agencies. It is worth noting that as in all industries, the quality and capacities of these
agencies can vary greatly. It will, therefore, be important to understand and consider the experiences of these agencies
in working on similarly focused campaign work.
As part of this assessment, three senior managers agreed to discuss their experiences working with development/aid
sector clients and the government with the understanding that they would not be directly identified. The first two
(Managers) oversee business units within large international PR firms with portfolios that include development
communications and social marketing. The third (Owner) is the owner/operator of a boutique firm in Jakarta who works
with both the private and development sectors.
The first Manager, who has a background in development communications and public information strategies
acknowledged that many large PR firms are uncomfortable working in the development sector because,
“They [development organizations] often don’t understand how it works. They are learning that
communications and outreach supporting development projects like those in health cannot be packaged and
sold the same way one sells a cola or a car. There are monitoring and evaluation requirements that differ from
those of the private sector. At the same time, their expertise in social marketing is growing and they can bring
their marketplace experience and contacts into play in ways that are useful, innovative and support
sustainability. ”
Some of these firms are also dissuaded from submitting bids in response to tenders for communications services by
what is seen as overly complicated and bureaucratic reporting requirements, fee/payment schedules and a lack of
understanding in development circles about how the private sector operates. In the context of a stunting campaign for
example they are challenged by a lack of operational experience in remote, under-serviced areas where stunting is
more severe. With few exceptions they are more comfortable in boardrooms than posyandu.
That said, because of their global reach, large firms with backgrounds in development communications and outreach
may be able to draw upon and adapt relevant lessons learned from experiences in other countries, he said. They offer a
“one-stop solution” that is attractive from a project administrator and procurement perspective, and campaigns relying
on extensive television advertising will benefit from the cost savings large firms can provide.
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Furthermore, smaller domestic firms that have worked in the development sector may enjoy a competitive advantage
in some areas due to their relative familiarity with the local context.
“I know the work we have done in NTT, NTB and Papua gives us an advantage because we’re able to identify
with the challenges our clients face implementing aid projects,” he said. “We’re also quite a bit more flexible
because the managing director is usually working directly with the client rather than handing the project to a
staffer, and cheaper because we don’t have the kind of overhead that a large firm has.” He also noted that a
large component of his development-sector business is sub-contracts from international firms, “so you’re
paying them a large fee to sub-contract to us”.
The Owner acknowledged that small firms often lack the administrative and human resource capacities required for
large development sector initiatives, and they do not enjoy the clout large firms have when it comes to buying large
blocks of media time.
Both the Managers and the Owner noted that development sector clients frequently have no idea how public relations
firms operate and benefit from having an experienced public communications specialist directly attached to the project
in question.
“When I’m dealing with project managers with no background in PR or communications it’s like we’re talking
two different languages,” the second Manager said. “We end up wasting a lot of time and energy.”
The apprehension experienced by staff of communication agencies, was also felt by the government officials:
“We have been experiencing difficulties with the contractors that managed to prepare an excellent write up in
paper or proposals, but in the end completely failed in delivering what was promised.” (Staff of Ministry of
Health)
Lack of understanding regarding each other’s’ working processes seemed to hinder a constructive collaboration
between the government and the communication agencies. The interaction between them will need to be facilitated by
a strong team that understands both the technical side as well as the communication aspect of the campaign.
X. Engaging the Private Sectors
Several stakeholders mentioned the importance of working together, including with the private sector. Public Private
Partnership (PPP) is seen as an opportunity to leverage the campaign to reach a bigger audience. The private sector’s
expertise in promoting commercial products, particularly fortified products, is seen as a strength that can be utilized to
improve the strategy. However, there are a number of challenges to working effectively with the private sector,
especially around marketing of food products, which must be addressed prior to partnership. Furthermore an exact
mechanism of collaboration seemed uncertain at this point, especially since similar such engagement has not yet been
successfully implemented as part of a community nutrition program aimed at increasing market access in remote parts
of Indonesia.
LESSONS LEARNED
The following are among the noteworthy conclusions drawn from the case assessments, interviews with domestic and
international communications specialists with expertise in health campaigns in Indonesia and the author's own
experiences:
1. Careful Formative Research Anchors Successful Campaigns
The development and application of suitable approaches and tactics to awareness-raising and behavior change is
predicated upon formative research that identifies target audiences, provides clear insights into how individuals and
communities make decisions, and the social and economic drivers behind those decisions. The need for research is
19
particularly acute in regard to stunting because of the lack of understanding about what it is, and the perception that
stunting is 'normal'. Parachuting in messaging and materials with no clear appreciation of the local context and
behavioral drivers will not work.
2. Development of a Comprehensive Strategy
Lack of a comprehensive strategy truly hinders the effectiveness of past campaigns. Many communication activities
were conducted in an ad-hoc manner, resulting in inconsistent messaging and “branding”. A communication guideline
on nutrition should be developed to provide stakeholders with clear directions regarding the key behavior change
objectives and correct messages related to them. The guideline will also allow other relevant organizations or the
private sectors to support the campaign, while minimizing the risk of having conflicting messages.
Priority issues need to be decided early in the campaign based on the results of the formative research. The campaign
should focus only on selected strategic behavior change objectives that may yield the most significant results. There is
no use in choosing too many issues or information to disseminate as they will hinder the conveyance of a clear message
and create confusion.
3. Clear Coordination and Decision Making Mechanisms
Successful communications campaigns require prompt decision-making at all levels, informed by technical inputs from
individuals who have expertise not only in nutrition, but also in behavior change communications. An important lesson
for the campaign will be establishing an ad-hoc team of relevant that can inform decision-making particularly on
campaign design, messaging, implementation and evaluation. Ideally, this team should consist of under five members
who establish clear decision making processes prior to the group’s inception. Group discussions and decisions should be
linked back to campaign management, as well as other efforts that support nutrition behavior change communications,
including the SUN (Scaling Up Nutrition) Framework and management structures.
4. Building Support for Campaign Goals at All Levels is Critical to Its Success
One of the direct impacts of regional decentralization in Indonesia has been the transfer of considerable authority to
the provincial and district levels. For this reason, any campaign strategy should include a detailed approach for
engaging stakeholders at all levels of government, and across ministries including those that might not typically be
involved in health and nutrition policy-making. While national-level support will help to open doors initially, a
campaign’s strength will be connected to the level of investment at the sub-national level. Also related to this is the
importance of active participation and support of elected and non-elected government officials (e.g. civil service), who
also play a role in dictating health policies and projects at the sub-national level.
5. Use and Enhance the Available Tools and Channels
Successful, research-based campaigns identify and engage existing, proven village-level social and political structures to
serve as communications channels, champion the cause, bear and articulate messaging and reinforce the broader
project goals. These include the business and religious communities, labor organizations, women’s and youth groups,
and local artists.
The closer-to-home theme extends to campaign materials. In successful campaigns, the target audiences have seen
themselves reflected in its attributes containing relevant linguistic and cultural touchstones. For example, the use of
light-skinned models with long noses considered esthetically pleasing in Java, do not resonate in the same way in parts
of rural NTT and NTB. In order to ensure that the tools used during a campaign are geographically appropriate, a firm
20
should ensure that communities are enlisted as partners in the campaign's design, and throughout the process of
rigorously pre-testing the campaign’s message.
6. Ensure Consistency of Campaign Messaging and Design
Regardless of the platform; on- or off-line media, one-on-one or group discussions, mass events, campaign materials
such as posters and flyers, awareness-raising videos; broadcasted public service announcements must have a consistent
look, design and message in order to build recognition among the broader community.
Related to this idea is the importance of ensuring any message is simple, clear and easy to understand. Effective
grassroots outreach and education campaigns acknowledge and respect variation in the levels of education among
different target audiences by focusing on a single and simple to understand message. This effect is amplified, in some
cases, through the use of musical jingles and/or catchy slogans. Many political campaigns use simple rhymes and hand
signals reflecting their ballot numbers to enlist support for “Team Number Three” for example.
Finally, involving local people in the development and field testing of outreach materials builds trust and buy-in and
ensures they are relevant and understandable.
7. Harness The Power of Local Celebrity
One of the lessons learned from many successful past awareness-raising campaigns, is the importance of engaging local
or national celebrities early and often as ambassadors and spokespeople for a particular issue. Being able to associate a
well-recognized individual with a particular issue, along with campaign promotional materials, helps to increase issue
recognition and popularity among community members.
8. Understanding the Importance of Early Media Development
Media landscaping should be conducted as one component of the formative research phase of any child stunting
prevention campaign. In this way, media landscaping will provide insight into the print and broadcast penetration in
project intervention areas and inform possible media buys in those areas. Modest investments in district and/or
provincial-level workshops will empower local journalists, who are often offered very few professional development
opportunities, to better cover health issues, in general, and to articulate the “new” understanding about the nature of
stunting. Conversely, the failure to engage media risks perpetuating old beliefs and stereotypes.
Related and worth exploring is the penetration and active usage of social media (Facebook, Twitter, Pinterest, Google+
etc.) by key target audiences, particularly in urban centers where power supplies are relatively stable and internet
access readily available.
9. Monitoring and Evaluation
Monitoring process for the campaign is important to provide short term feedbacks regarding the implementation of the
campaign as well as to confirm that the strategy is being implemented according to the plan and schedule, while
evaluation is needed to measure the result of the campaign and document the lesson learned.
Planning the research in the beginning of the campaign is essential to make certain that results are measurable and well
documented. The terms of reference of the evaluation is beyond the scope of this situation analysis, but clear behavior
and communication indicators must be incorporated in the research.
10. Successful Campaigns Also Address Gender Concerns
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Incorporating information from a gender analysis into a health communications campaign at the onset has the potential
to extend the reach and impact through strategic identification of differing roles and needs of men and women,
benefits, power dynamics, household decision-making processes and socio-cultural constraints. This is especially true
for the unique circumstances that surround health seeking behavior in Indonesia, specifically with regards to children.
Traditionally decisions and budgeting for children’s health and nutritional needs is viewed primarily as a women’s
responsibility.
There are a number of precedents for this in the Indonesian experience including the Suami Siaga Campaign (see case
studies) which focused squarely on the roles of husbands in the provision of timely maternal health services to their
wives. The Suami Siaga program successfully delivered behavior change communications efforts that engaged
husbands of expectant mothers as central actors in the preparation for childbirth by creating very specific roles and
responsibilities for these men related to reducing delays in their pregnant wives seeking and receiving timely medical
attention.
Gender awareness can help communities find culturally appropriate ways to change existing beliefs, attitudes, and
social norms that restrict gender equity and equality. In this way, health communications programs can be powerful
tools for encouraging community members to pay attention to resolving gender inequities. It is also important to
understand that health behaviors, practices, or actions promoted by health communication programs may precipitate
direct or indirect changes in gender roles. Should changes occur in gender attitudes or roles, these should be defined
early, clearly and include them in the outcome indicators.
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PART 3: THE WAY FORWARD: A CAMPAIGN APPROACH
A detailed strategic partnership approach to a two-tier (local and national) campaign to raise awareness and to reduce
stunting will address two key issues:
Low Existing Levels of Awareness/Understanding: There is a fundamental lack of familiarity with the subject of
stunting across critical target groups from the MoH down to the village level including entrenched misconceptions
(e.g. genetics determine height-to-weight ratios) and thus has no link to the nutritional status of children.
Need for Broad Multi-Stakeholder Buy-in and: Past experience has shown that a successful stunting
communications campaign requires the engagement and empowerment of multiple tiers and elements of society.
Partnering with an established national program or programs will better address the government’s priorities and
ensure their support.
Based on the lessons learned and steps identified in various references, the following approach to a stunting campaign
is recommended:
PRE-CAMPAIGN
1. Situation Analysis
This document is part of the effort to determine the scope and scale of past health communications
campaigns, identify best practices, commonalities in approaches, communications channels, materials and
experiences with contractors. The conclusions will then be utilized to design an approach to a multi-year
national awareness campaign about stunting.
2. Obtain inputs and share the result with relevant stakeholders
The issue of stunting involved various government entities and organizations, therefore it is crucial that
relevant stakeholders are consulted and well informed about the general plan to ensure common
understanding.
PHASE I: YEAR I
1. Formation of ad-hoc team that includes relevant stakeholders
A communication campaign requires prompt decision-making at all levels and the process needs to be
facilitated by establishing an ad-hoc team that will give final decisions regarding the campaign. Members of
this team should come from relevant stakeholders (i.e. MCC-I, Bappenas, Nutrition – MoH, Health Promotion –
MoH, etc) and are given the authority to make decisions regarding the direction of the campaign. Ideally, there
should not be more than five members of the team to ensure easy coordination. A clear decision making
process should be developed and agreed upon to facilitate efficient management of the campaign.
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Figure 1. Proposed Organization Structure to support the Health Communication Campaign Strategy
In addition to representatives from MCC-Indonesia, the ad-hoc communication team should include:
- Ministry of Health
- The National Agency of Food and Drug Control (BPOM)
- Ministry of Internal Affairs
- Ministry of Communication and Information Technology
- Ministry of Agriculture
- National Planning Board
The proposed organization structure, suggested time frame, and campaign steps that were presented by the
Consultant during the discussion received an approval and support from all of the informants. (See Figure 1
and Table 1).
2. Complete assessment of institutional capabilities and decide on basic responsibilities (including hiring the
team to manage the campaign if needed)
It is also important to identify the available resources within the network of stakeholders involved in the
project that can be mobilized (i.e. technical expertise, human resources, funding, etc.) and pinpoint the gaps.
Clear division of tasks and responsibilities should also be discussed and established from the beginning to
warrant smooth implementation. If internal human resources are not sufficient, then decisions should be
made to hire personnel that will be in charge of the campaign management.
3. Review existing information and analyze information gaps
After the priorities and objectives are set, further investigation is needed to identify what kind of data and
information are available to explain the current behaviors and the reason why the recommended behaviors
are not being implemented. Identifying the gaps will be the foundation to the design of formative research
Contractors are companies that are selected through a competitive selection process that requires
specific expertise in the implementation of the campaign.
The campaign management team is the team that is responsible for the
day to day management of the campaign and oversee contractor’s
performance
The ad-hoc communication team is the cross-sectoral team that is
responsible to provide the direction of the campaign and provide final
decision making
Scale Up Nutrition (SUN)
Structure
Ad Hoc Communication
Team
Campaign Management
Team
Contractor
Formative Research
Contractor
Advertising Agency
Other Contractors
24
later on in the process. If internal resources are not available to conduct this process, consultant/s will need to
be hired.
4. Determine and gain consensus on broad communication for behavior change objectives based on overall
project goals
Stunting includes various different issues and challenges. Therefore, clear priorities regarding the general
direction of the campaign should be set by the team based on the review of available data and information.
We need to bear in mind that these will only be preliminary focus of the campaign and it will be confirmed
through the formative research.
5. Selection of contractor for the formative research
Based on the information gaps identified during the review of existing information, research objectives should
be set for the initial formative research and be used to develop the ToR. Considering the scope of the research,
it is very likely that an organization will need to be hired to carry it out. Selection of the research contractor
should be conducted through a competitive bidding process. A sample of the ToR is attached in Annex V.
6. Plan and conduct initial formative research
Formative Research is the cornerstone of successful communications campaigns. Assessing Knowledge,
Attitudes & Practices (KAP) of target audiences is the bedrock of successful behavior communications
campaigns. Formative Research/KAP & Social Mapping identifies the key relevant issues and influencers of
your target audiences, including a particular focus on gender constraints. It also identifies factors that may
predict willingness to consider new behaviors (e.g. literacy levels, information-seeking behaviors, extent to
which grandparents/elders or in-laws impact decisions of adult children).
Researchers should also be instructed to identify locally-relevant “gateway moments”, those key transitional
points in a person, family or community’s life during which they may be receptive to information that can lead
to significant behavior change, including a first pregnancy and the birth of a first child. While household-by-
household level assessments are not practical for a project of this size, trends can be identified that will help
fine-tune the audience selection, inform the development of the strategy and approaches, and the production
of suitable outreach materials & messages.
7. Review of formative research result and design a general campaign guidelines and creative brief
A campaign creative brief20 and ToR will be developed and agreed by the ad-hoc team. All project stakeholders
will then be engaged to ensure that the brief meets all institutional needs and is consistent with the priorities
set early in the process. The brief and ToR will also be used to provide background information for the
prospective advertising agencies.
8. Selection process for advertising agency and other relevant companies
The brief and ToR should be disseminated to prospective advertising agencies and a special briefing session
should be conducted to explain the project to them to ensure their understanding on how behavior change
needs to be brought about through their work.
20 A creative brief is a document that highlights a general strategy of the campaign that will be used for communication agencies to develop the creative concept of the campaign.
25
In addition to the brief and ToR, a document should also be developed to create a set of criteria for selection.
In general, the prospective agencies invited should be able to demonstrate: 1) the ability and previous
experience in handling a campaign at the national level, 2) creativity, 3) familiarity with government system,
especially in health care, 4) an experienced team and 5) high quality of service (based on references).
The process usually comprises several steps:
a. Invitation to bid (i.e. open bid through advertisement or selective bid by invitation)
b. Preliminary selection, which typically selected 3-5 communication agencies to participate in the next level
c. Communication agencies briefing (i.e. sharing of the creative brief)
d. “Pitching” or presentation of creative concepts and campaign management plan by the agencies
e. Evaluation and selection
f. Announcement of winner
9. Develop behavior change strategy, including its communication component but also link to training needs,
products, etc
Once the advertising agency is selected, its main task is to develop the campaign strategy in three steps: 1)
conceptual outline, 2) main components, and 3) detailed design. The strategy should include key messages and
media plans. To ensure appropriateness of strategy, the draft should be pretested to the suitable target
audience during the process before finalizing the messages and materials. Additional formative research can
also be implemented if needed.
PHASE II: YEAR II – IV
1. Stakeholder meetings to gain consensus on the behavior change strategy
The agency should consult with the ad-hoc team for inputs and approval prior implementation. The ad-hoc
team will also ensure that the communication strategy be consistent with the national nutrition and other
health programs relevant to stunting.
2. Assign responsibilities for materials preparation, training and remaining research, including monitoring and
evaluation
Distribution of tasks and responsibilities must be clear, especially since various organizations will be involved in
the process. Multiple tasks will be carried out at the same time, therefore coordination is key to ensure that all
will be implemented according to the strategy.
3. Produce the communication for behavior change materials
Mock-ups or storyboards (in the case of television advertisement) will be produced and pre-tested to the
appropriate representatives of the target audience. Once they are reviewed and revised, production can
commence.
4. Prepare to implement communication and other components of the behavior change strategy including
training
To ensure that the campaign will be endorsed at all levels; efforts must be made to advocate support from
various sectors including government officials at the district level and beyond, as well as the private sector.
Training for health volunteers, health workers and other social mobilizers might be needed to ensure that they
are familiar with the messages of the campaign and able to disseminate them.
26
5. Plan, conduct, and analyze a baseline survey
It is important to differentiate between a baseline survey and formative research. The latter is conducted to
design the campaign, while the former is conducted to properly measure changes resulted from the campaign
activities. Although both can be implemented at the same time, they serve different purposes and should be
designed appropriately.
6. Launch campaign
The launch of the campaign is typically a big event designed to draw attention to the start of the campaign and
preparing the general public to pay attention to the issue. Past campaigns have been attended by various
dignitaries, including celebrities who acted as the ambassadors. The launch of the campaign is usually a
massive undertaking on its own, which may require a qualified event organizer to ensure smooth
implementation.
7. Implement communication activities
Depending on the strategy, several activities may be implemented throughout the campaign including (but not
limited to): media advertisement (including television, radio, and print), public relations, events and
community outreach activities, advocacy meetings, and social media campaigns. All of these activities will need
to be coordinated to ensure consistency and coherence.
8. Monitor and adjust project activities
To ensure that all activities are implemented according to plan and allow revisions throughout the campaign,
monitoring must be conducted. Monitoring activities require proper planning and allocating of resources.
Good monitoring will allow the campaign to be revised quickly when things are not going according to the
plan.
PHASE III: END OF YEAR IV AND BEYOND
1. Plan and conduct an impact evaluation
As stated in the previous section, lack of evaluation has been one of the major problems in the past. The lack
of documentation of previous campaigns’ successes and failures made it especially difficult for future
programs to learn from the experience.
2. Disseminate project achievements and lessons learned
In order to ensure that lesson learned from the campaign can benefit future campaigns, activities to
disseminate the experience must be conducted.
27
Project Phases Time Frame Steps in Communication for Behavior Change
Preliminary Assessment
Pre-Campaign: 2012
Q4 Carry out communication situation analysis
Q4 Obtain inputs and share the result with relevant stakeholders
Identification Phase I: 2013 (Y1)
Q1 Formation of ad-hoc team that includes relevant stakeholders
Q1 Determine and gain consensus on broad communication for behavior change objectives based on overall project goals
Preparation Q1 Review existing information and analyze information gaps
Q1 Complete assessment of institutional capabilities and decide on basic responsibilities, including hiring of technical consultants
Q1-Q3 Plan and conduct initial formative research
Appraisal Q4 Review of formative research result
Q4 Design a general campaign guidelines
Contracting Q4 Selection process for advertising agency and other companies if needed
Development Q4 Develop behavior change strategy, including its communication component but also link to training needs, product, etc, including pre-testing the materials
Q4 Stakeholder meetings to inform and gain consensus on the behavior change strategy
Implementation Phase II: Year 2014-2016 (Y2 – Y4)
Y2 Q1 Assign responsibilities for materials preparation, training and remaining research, including monitoring and evaluation
Y2 Q1 Produce the communication for behavior change materials
Y2 Q1 Prepare to implement communication and other components of the behavior change strategy including training
Y2 Q1 Plan, conduct, and analyze a baseline survey
Y2 Q2 Launch campaign
Y2 – Y4 Implement communication activities
Y2 – Y4 Monitor and adjust project activities
Evaluation Phase III: End of 2016 (Y4)
Y4 Q4 Plan and conduct an impact evaluation
Completion After 2016 (Y4 – beyond)
Y5 Disseminate project achievements and lesson learned
Table 1. Proposed Campaign Timeline and Activities
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ANNEX I. CASE STUDIES This situation analysis reviews more than 30 past health projects undertaken by the Government of Indonesia
and various local and international agencies. However, five case studies were chosen to provide detailed
lessons learned that are most likely to produce successful outcomes for a stunting campaign (the complete list
of all program reviewed for this assessment is included in Annex I).
BLUE CIRCLE CAMPAIGN (LINGKARAN BIRU)
Introduction to Blue Circle
Indonesia is a pioneer in family planning social marketing and educational campaigns. Blue Circle was arguably
the best-known social marketing experiment in Indonesia. It certainly had been the most memorable as many
of the stakeholders interviewed mentioned it as one of the most successful campaigns they could recall.
In 1971, there was an average of 5.6 live births per woman in Indonesia. Family planning objectives were to
ultimately reach a national two-children-per-family average by reinforcing the ideal of “A small, happy, and
prosperous family” beneath the campaign slogan, Two Children Are Enough (Dua Anak Cukup). The Indonesian
government provided funding, with major donor support from USAID and AIDIW, World Bank and UNFPA.
In the mid-1980s the government agreed to a funding structure supported by private sector providers to
reduce the burden on the government's budget and the umbrella Private Sector Family Planning (PSFP) project
was developed with the goal to assist public and private sector actions leading to a self-sustaining system for
reducing fertility from 3.4 children in 1987 to 2.4 by 2000. During this time the concept of KB Mandiri (self-
reliant family planning, which in practice means paying for family planning services as opposed to receiving
free services) was implemented and, in 1988, with the support of USAID, the public-private sector partnership
known as the Blue Circle institutional branding and social marketing program began.
During its 35-year involvement with the BKKBN until 2006, USAID contributed US$340 million to Indonesia’s
family planning program. The Blue Circle program was supposed to be its final bilateral support effort for the
Indonesian national family planning program.
The goal of the final Blue Circle program was to:
- increase contraceptive prevalence from 48 percent to 53 percent;
Program Implementer Government of Indonesia
Program duration 1988-1996
Program goal Strengthen Family Planning
What is the Indonesian Family Planning Program?
The National Indonesian Family Planning Program, supported by the
Indonesian National Family Planning Coordinating Board (BKKBN),
was established in 1970 and over the next 25 years developed a
strong family planning infrastructure at all levels of government.
29
- increase the percentage of couples using private sector doctors, midwives and pharmacists as the
source of family planning services from 12 percent to 20 percent;
- increase the percentage of couples paying for family planning services from 23 percent to 50 percent
in urban areas and to 40 percent in rural areas; and
- increase nationally the percentage of couples paying all or part of the costs of family planning services
from 36 percent to 45 percent.
Blue Circle promoted private sector doctors and midwives as the key vehicles for the delivery of urban family
planning services. Offices bearing the Blue Circle brand came to be associated with the provision of reliable,
top-quality family planning services. Over the course of the first three years, the campaign rolled out from the
original four target cities to more than 300 cities and towns nationally.
The BKKBN, through the IKB-Somark project, went on to launch the Dua Lima (Two Five) condom, one of four
private sector contraceptives approved for Blue Circle branding, and the parallel KB Mandiri campaign
encouraged the population that had hitherto received contraceptives for free through public sector clinics and
hospitals, to instead pay for the products.
The project was so successful in reaching consumers through mass media and public relations/social marketing
that it paved the way for subsequent initiatives including the BKKBN launching the Gold Circle campaign.
Key Messages
1. Small, happy, prosperous families
2. Two Children Are Enough
Activities
It is worth reviewing the scope of Blue Circle activities to appreciate the scale of the effort.
1. To promote the delivery of services by the private sector (managed by BKKBN), training in family planning
techniques was delivered to
- 1,600 doctors - the effort was ultimately terminated because of difficulties finding doctors willing to
devote time to the training at a time when general practitioners were not considered suitable for
delivering family planning services.
- 5,400 midwives - twice the amount originally projected when it became clear that they were the most
popular sources of family planning services.
- 2,000 pharmacists.
- To promote Community-Based Distribution of Contraceptives (which were focused on the eight most
populous provinces and managed by BKKBN). The activities included training of 286,000 BKKBN
fieldworkers, volunteers and community leaders over a three-year period to distribute non-clinical
contraceptives for a small fee, refer clients to private providers, promote the use of long-term
contraceptive methods (LTM) and set up community contraceptive funds to help families unable to
afford contraceptives.
2. To promote demand, a Social Marketing campaign was undertaken, which became the flagship of the
PSFP project managed by USAID, BKKBN, the PSFP project contractor and sub-contractor, a management
sub-contractor, four large pharmaceutical companies and their distributors. The activities included;
- Market research, strategic planning, mass media advertising, public relations, and establishing credit
systems for providers to first introduce the Blue Circle logo to key stakeholders
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- Introduction of four Blue Circle-branded contraceptives (an oral contraceptive, IUD, injectable
contraceptive and condom).
3. To promote increased use of IUDs, vasectomies (VS) and implants by improving the quality of clinical
services, activities included;
- The renovation and equipping of hundreds of clinics for LTM, especially voluntary sterilization (VS),
training for physicians and providing support to the Indonesian Society for Secure Contraception
(PKMI) to promote VS and to establish, introduce and monitor quality control.
- Reimbursement program to hospitals for each VS procedure.
- IUD and implant training for private sector general practitioners by the Indonesian Medical
Association (IDI) in coordination with BKKBN's Bureau of Integrated Program Services (BINSI) under
the Private Sector Delivery project component.
Assessment
Overall, the results were remarkable. By 1994, 28 percent of eligible couples were using the private sector for
their contraceptive needs, compared to only 12 percent in 1987. Surveys conducted a decade later tracking the
effects of all the BKKBN’s campaign efforts – of which Blue Circle was one component – show more dramatic
results: 91 percent of users were paying for their contraceptives.
In 2006, AC Nielsen reported universal awareness of the top two family planning methods in Indonesia and
over 90 percent awareness of condoms, implants, and IUDs, for example. There are many reasons why the
campaigns themselves were successful, but three key elements were the sustained public support of President
Suharto, the relative political stability of the period, and the extensive use of compliant, state-controlled media
to carry and reinforce the messages.
While Blue Circle contraceptives were mainly distributed in urban areas, mass media advertising nation-wide
assisted efforts by Community-Based Distribution (CBD) workers to engage the rural private sector. The Blue
Circle campaigns and service providers convinced a majority of survey respondents that the products were
accessible, affordable and high quality.
The use of LTMs increased only marginally to 36.5 percent, the number of VS procedures declined steadily
each year, and the use of IUDs also fell from 13.2 percent of eligible couples in 1987 to 10.3 percent in 1994.
Only increased use of contraceptive implants kept the percentage of LTMs from declining.
Lessons Learned
1. There are three elements necessary for success and sustainability of contraceptive social marketing:
affordable and accessible products; quality providers and quality products; and effective promotion.
2. A significant number of rural couples are willing to pay fully or partially for quality contraceptive products
and the BKKBN demonstrated that it can organize and implement massive training programs with only
limited donor technical inputs.
3. Without sustained mass media promotion, the private sector share of the contraceptives market would
not have more than doubled. Three-quarters of respondents stated the best way to reach target
audiences was through television.
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4. More in-depth formative research would likely have revealed that midwives play a much more important
role in providing FP information and services than general practitioners or pharmacists.
5. Religious, programmatic, and political sensitivities may have contributed to VS not gaining traction.
Politically, there was a prohibition by the government of mass media VS promotion; programmatically, VS
is a medical procedure, not a family planning program method, and religiously, some Islamic leaders are
against VS because of its permanent nature.
6. A successful VS program requires publicity and strong government support. Expansion of facilities,
provision of equipment, training staff, and development of standards and monitoring capability are not
enough.
THE WEANING PROJECT
Program Implementer Manoff International Inc. (now The Manoff Group). USAID-funded
Ministry of Health of Indonesia
BKKBN
Program duration 1985-1989
Program goal Investigate young child feeding practices and design nutritionally sound, low-cost,
and sustainable methods to improve them.
Introduction to the Weaning Project
The Weaning Project is one of the most useful and relevant case studies for the development of a national
stunting communications effort in Indonesia for a number of reasons; public communications, education and
outreach were the central components of the project; it focused on a child’s earliest nutritional challenges
(birth-through-two years of age) and so is directly relevant to stunting; it aligned with existing GoI priorities
articulated through from an existing successful initiative and messaging (Blue Circle; Small, happy and
prosperous families); involved government and other stakeholders from top-to-bottom, and it was guided by
relevant research.
It had become increasingly clear by the mid-1980s that young child feeding and associated household practices
were a major cause of poor child growth in developing countries like Indonesia. Pilot projects had shown the
potential existed to improve these practices and enhance child growth through the use of effective, research-
based communications tools and approaches.
In early 1985 Health officials requested assistance to enhance the education component of their national
Family Nutrition Improvement Program (UPGK). Project staff worked with Nutrition Directorate of the
Department of Health of Indonesia and others to form the Central Working Group (CWG) to coordinate project
activities and standardize monitoring and evaluation and reporting. Provincial Working Groups (PWG) were
also established under the auspices of the head of the provincial nutrition directorate, with membership from
provincial BKKBN and health education staff. District and sub-district working groups were created to ensure
that implementation plans were tailored to local agendas.
The project focused on East Java and West Nusa Tenggara (NTB) provinces. One semi-urban and one rural sub-
district in each location (Pasaruan and Lombok) were targeted with coverage ultimately expanding to at least
32
one complete district in each province to capture differences in child feeding practices in very different
environments.
To foster sustainability, an advisory group was created, comprised of members of local development agencies,
other directorates of the Ministry of Health and other line ministries. The group met periodically to help with
certain project decisions, to learn about particular innovative methods and to assist in disseminating project
methods and findings within their own agencies or units.
The project settled on the following targets:
• To contribute to the reduction in the infant mortality rate through improvements in the nutritional status of
infants and young children that tied into BKKBN’s existing “small prosperous family” messaging.
• Describe weaning practices, influencers, and behavior change potentials in East Java and NTB as models of
the basic types of information and analysis provincial authorities need to replicate.
• Develop, implement, and evaluate province-specific educational strategies for improving weaning practices
in target areas.
There were four Phases:
Phases I - Research – One Year
Research component took approximately one year and had four components:
Four components:
problem identification.
problem analysis and concept formulation
intervention testing/household trials
synthesis of the information
Largely qualitative in nature, it employed the following approaches: Focus Group Discussions, dietary food
recalls, structured observations, morbidity recalls, trials of new practices, and ethnographic assessments. It
focused on weaning practices, the mothers’ knowledge and the beliefs and values sets underpinning her
behavior. Modified practices based on early data analysis were field-tested, assessed and the results used to
inform development of education strategy in Phase II includes an assessment of information sources for
women, including broadcast media, traditional and/or religious events, attendance at monthly posyandu
events etc.
Phase II - Strategy formulation, materials design and production, and preparation for launch – 16 Months
Based on the results of the assessment phase, behavior change objectives were set and an overall
communications strategy was developed. The strategy included identification of major concepts, channels of
communications to be used (media), materials to be developed, and a schedule and budget for
implementation. Once the strategy was agreed upon, a local advertising agency was contracted to assist in
designing, pre-testing and producing the materials.
A three-day strategy-development workshop organized by the CWG brought the members of the PWGs, the
Ministries of Planning, Religion and Agriculture, the National Family Planning Board, universities, private
institutions, UNICEF, and USAID to discuss the results of the assessment, create a general project strategy and
province-specific plans.
33
The strategy formulation workshop concluded:
1) The Weaning Project should limit itself to communications and training activities. Participants felt
requirements for interventions like food production or improving distribution would exceed available staff and
financial resources.
2) The communication and training activities should have two focal points: posyandu/UPGK weighing sessions
and be integrated into a variety of government programs and community activities.
3) Emphasis should be placed on strengthening the kader's role as educator.
The CWG was tasked with writing the detailed communication and training strategy and identified the need for
private sector assistance. As work commenced on this, it was clear that a local company with creative talent
and knowledge of Indonesia's media situation would be required to assist the CWG with the details of the
strategy, developing and testing the prototype materials, finalizing them and overseeing their reproduction. To
this end a contract was signed with an experienced Indonesian marketing firm with a background working with
the government.
Phase III - Implementation: 21 months
This phase began with training activities for health workers, shopkeepers, women's group representatives,
religious leaders, midwives, and village officials. Educational activities were implemented in the field, following
a predetermined schedule. Supervision and in-process monitoring took place on a regular basis. Based on the
results of the monitoring, revisions were made as needed during project implementation.
Phase IV - Evaluation
Baseline Survey: July - August 1987 Follow-up Survey: February 1989
The design of the evaluation was for pre- and post-measures of the mothers' knowledge and practices and
their infants' calorie and protein intake and nutritional status in a program and comparison sample. A cohort
study was also done: children under nine months of age at the time of the baseline were revisited during the
follow-up survey. This phase began with a baseline survey of 780 mothers with children under 24 months.
“The objective of the assessment phase was to understand the rationale behind existing child feeding
practices, not just to document practices. The emphasis in the process was on obtaining an in-depth
look at feeding practices within the broader household and community context. Also, it was to identify
the major resistances to changing those practices and the important motivational factors to
encourage change.”21
Messaging
The social marketing approach and messaging strategy intended to:
Introduce a "product", in this case good and proper weaning practices, that is superior
to the existing “product” and will fulfill the needs of parents.
Create consumer acceptance for "good and proper weaning practices" by promoting them through
credible local sources with good coverage and contact with the target audience.
"Outsell" the competition, old attitudes and practices related to infant and child feeding, by
improving knowledge and self-confidence of mothers in their ability to change.
21 The Weaning Project: Improving Young Child Feeding Practices in Indonesia: Project Overview. Nutrition Directorate, Ministry of Health
and the Manoff Group Inc. 1991; Page 8
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The assessment informed the project that mothers do not have a complete understanding of
appropriate feeding practices, do not recognize what constitutes nutritious food for their babies or
know adequate quantities they should be fed. Thus the Concept of Good Proper Weaning Practices is
the foundation of the of the outreach strategy “because it summarizes the "product" the project is
trying to sell.”22
A broad segment of society was identified as target audiences including mothers/fathers of under-twos and
other caregivers. The principal audience, mothers, was segmented based on the factor that most distinguished
their feeding practices: age of children, the child’s current state of health, and whether the the mother was
extremely occupied.
The key points of direct outreach were through the posyandu, in UPGK programs outside posyandu and in the
private sector through local shopkeepers. The kader and bidan, community and religious leaders, heads of
women’s groups and merchants were all generally regarded as reliable sources of information and useful
vehicles to disseminate information. The main media engagement was through local radio stations (dialogues,
PSAs, jingles for the stations, and eight cassettes for different age groups), and direct and group outreach
activities were supported by printed materials including posters, leaflets, counseling cards and a special child
feeding “schedule” card.
The materials were designed to be used across multiple media so that the basic “product” messages are
reinforced. The centerpiece was Ibu Gizi, (Mrs. Nutrition) who is the spokesperson for the project and seen as
credible and authoritative because she is mature and wise. She is behind all of the advice being disseminated
by the kadres and others who may lack credibility. All print materials carry her picture, and she is the leading
protagonist in the radio dialogues.
Training and orientation sessions were held to review the project’s goals, discuss the materials and messages,
and to socialize their use through role playing.
Assessment
The 1989 project evaluation survey (conducted one year after the campaign launch) concluded, the Indonesian
Weaning Project had improved mothers' and kadres' knowledge of child feeding practices, particularly
knowledge of breastfeeding practices, introduction of complementary foods, and appropriate mixed weaning
foods. Moreover, through (sic) this program involving educational inputs only, a significant impact was
observed (relative to comparison sites) in mothers' child feeding practices (especially those in the same areas
where knowledge increased), children's calorie intake, and the nutritional status of children.23
In other words, the provision of information and efforts to educate produced behavioral changes specific to
the overall goals of the project.
The vitality of local posyandu and the quality and commitment of its kadres was a key determinant in the
success of the project locally.
Some of the materials needed to be revised, reduced in number and the messaging made even more specific
and clear.
Activities outside of posyandu needed to be strengthened: for example, more stores and community groups
should be involved in the program. The initial idea was to involve almost all the small stores or food stalls in a
22 Ibid; The Weaning Project; Page 23 23 Ibid; The Weaning Project; Page 38
35
village but in reality only one or two per village had the materials, greatly reducing the visibility of the program
messages.
Women's organizations should be encouraged to implement the project, because when they are present at
posyandu, more educational activities are undertaken.
The provincial-level teams need to encourage the local radio stations to play the cassettes at least during some
of the time allotted for health programming. It would be better to play one dialogue at a time, instead of all
three to four dialogues created for one age group.
Once new materials are available, a retraining of kadres is needed to review communications skills. Special
care must be take that the kadres who are trained are the ones who are active at the posyandu.
The advisory group proved invaluable as a mechanism for informing and receiving comments from leading
nutrition programmers, the donor community and other key individuals over the life of the project.
Lessons Learned
The technical partnerships with the CWG, the PWG and advisory groups were effective in supporting the
projects sustainability goal.
It is important not to limit the program only to health channels, but to make it a community program. The
media mix and package of educational materials were deemed suitable and effective because even those
mothers who do not recall direct contact with the program have been influenced by it through word-of-mouth
contact with other mothers for example. The assessment also concluded that there’s value added when the
messaging becomes part of the local “environment” by engaging shopkeepers, religious leaders, women's
organizations, and village leaders to use the cassettes during community work parties or social gatherings not
specifically related to health.
The messages that had the most impact were precisely stated and had a name or a product identity associated
with them: Susu Pelinding (protective milk/colostrum) and Nasi Tim Bayi were seen by mothers as new and
appealing "products".
A set of core messages, language, specific foods, and some of the rationales for undertaking certain practices
will need to be adapted, but in a country as large and culturally diverse as Indonesia the educational
component should be expanded on a province-by-province basis to capture and reflect subtle changes in local
beliefs practices.
From the perspective of interpersonal communications, it is critical to remember that the kader and the entire
educational system is only as strong as the basic program infrastructure. Enhanced educational components
should go first to areas where the basic program is functioning well.
Effective supervision of kadres in their roles as educators was an important determinant in the effectiveness of
the message delivery.
36
POSITIVE DEVIANCE – HEARTH IN INDONESIA
Program Implementer USAID Food for Peace (participating institutions: CARE, Catholic Relief Services,
Mercy Corps, Ministry of Health, Save the Children USA, University of Indonesia,
and World Vision International)
Program duration 2003-2008
Program budget n/a
Program goal Reduce Malnutrition in Indonesia through Sustained Rehabilitation and Prevention
Mercy Corps was the first to discuss implementing PD/Hearth programs with the USAID mission on a large
scale and in 2002 Mercy Corps received funding through a Temporary Assistance Project (TAP) for districts of
urban Jakarta to implement PD/Hearth based programming.
Between the years 2003-2008, USAID funded CARE, Catholic Relief Services (CRS), Mercy Corps (MC), Save the
Children US (SC), and World Vision International (WVI) implemented PD/Hearth programs. These programs
were called pos gizi and were under the food security umbrella.
The project objectives include:
1. Rehabilitate malnourished children.
2. Enable families to sustain the rehabilitation of these children at home on their own.
3. Prevent malnutrition among the community’s other children present and future.
Messaging
The final report of PD/Hearth Indonesia provides few insights into specific messaging beyond noting:
What was evident from the interviews and observations was that the messages in the PD/Hearth
sessions were too numerous and rarely related to the PDI (PD Inquiry) findings.
The final report concludes:
Prioritize the most important health messages and only those directly related to improving nutritional
status. There are many good health behaviors, but the pos gizi must focus only on those directly
related to improving nutritional status. Mothers can absorb only a limited number of messages during
the pos gizi. Therefore, kadres must select the most important nutrition and health practices to share
and demonstrate during the pos gizi session.
Introduction to Positive Deviance
Why are the children of one poor family healthy while the children of
another poor family, living in the same community under very similar
circumstances, are under-nourished and unhealthy? Positive Deviance
(PD) within the context of nutrition and/or stunting is based on the
premise that there are individuals and groups who despite facing the
same kinds of economic challenges as their neighbors engage in
behaviors and practices that produce healthier children. The goal then is
to identify and disseminate those practices across the community at
large.
37
The inference from the above is that a limited number of clear, simple and relevant messages is optimal, and
that cluttering outreach efforts with information not directly related to the campaign’s goals is an unnecessary
distraction.
Assessment
Due to the professional monitoring and evaluation processes used by the five NGOs, data is available to assess
the effectiveness of the PD/Hearth process in ameliorating malnutrition.
In terms of nutrition status, research results illustrate that after 10 days of pos gizi participation, there was a
reduction in the percentage of children with severe and moderate malnutrition and increases in the number of
children with mild or no malnutrition.
The research showed that the program benefitted the extreme cases of malnutrition more than the moderate
cases. ‘According to the pos gizi monitoring data a greater percentage of children who entered with poorer
nutritional status gained 400g or more. Nearly half of the mildly malnourished children did not even gain 200g
during the month. This data shows that pos gizi may have been more effective for children starting with poorer
nutritional status.’
In regards to behavior change, a standardized set of behavioral indicators measured in the 2004 baseline was
created, but only World Vision International has completed their final survey of their work in North Jakarta and
Surabaya.
In general, positive changes were noted wherever there was an investment in behavior change. The project
evaluation identified the following communications/awareness-raising issues as key contributors to success:
High levels of understanding of PD by the individual kader.
Belief in the process of PD/Hearth by puskesmas staff .
High levels of awareness and understanding about the causes and consequences of malnutrition by
community leaders.
Active community support e.g. local leaders stopping by or providing food.
Lessons Learned
1. There was a direct correlation between community participation and success of a pos gizi. The use of
community members and project staff to jointly investigate and identify unique practices and strategies
used by caregivers with well-nourished children produces the best results.
2. Projects benefit from effectively disseminating a limited number of simple and relevant messages. In
practice this means identifying very clear target audiences and project goals, and avoiding the temptation
to try and get added value from materials by “piggybacking” multiple messages off the same platform.
3. Even with community support, sustainability remains a challenge. Researchers did not encounter kadres
who are implementing pos gizi on their own without support of an NGO or DHO. When asked whether
they could implement pos gizi on their own with community support, most kadres said they don’t have
the confidence in themselves, and couldn’t handle problems that might arise.
4. In terms of administrative challenges, working out the budgeting and formal agreements between
multiple agencies can consume much time and this must be allowed for in the timeline prepared for the
assessment.
38
SUAMI SIAGA / ALERT HUSBAND
Program Implementer Ministry of Health, Ministry of Women’s empowerment and child protection, John
Hopkins University Centre for Communication Programs.
Program duration 1999-2001
Program budget $ 750,000
Program goal Promote husband’s role to reduce delays seeking care, reaching care, and receiving
care for maternal health issues
Introduction to Suami Siaga
Roughly 18,000 of the 4.5 million women who give birth in Indonesia each
year die as a result of pregnancy and childbirth complications.
Since the late 1980s, Indonesia has been an active participant in global
movements to reduce maternal mortality and has been supported in its
efforts by many international development agencies. Starting in 1991, the
government concentrated its resources on training and deploying 54,000
bidan di desa (village midwives) throughout the country to deal with the
nearly 70 percent of childbirths taking place at home.
By the early 2000s, the government focused on improving the performance of the bidan, strengthening the
quality of care, and increasing service coverage for mothers and infants. The Mother-Friendly Movement
(Gerakan Sayang Ibu) launched in 1996 by the Ministry for Women’s Empowerment, used communications
and advocacy activities to mobilize various sectors in the government and community to address factors that
lead to maternal mortality. The Mother-Friendly Movement adopted Thaddeus and Maine’s Three Delays
conceptual framework, which emphasizes taking steps to reduce delays in deciding to seek care, reaching a
healthcare facility, and receiving care.
Introduction to Suami SIAGA (Alert husband)
The Suami SIAGA campaign was a multi-media edutainment (education & entertainment) initiative whose goal
was to reduce maternal deaths by increasing the involvement of husbands in a range of safe motherhood
initiatives. Implemented by the Ministry of Health and the Ministry for Women’s Empowerment, John Hopkins
University Center for Communication Programs and UNFPA the initial program had a budget of USD 750,000.
It was the first phase of an effort that would expand over time to include Warga (Citizens) SIAGA, Bidan
(midwives) SIAGA and Desa (Village) SIAGA. The SIAGA acronym combines Siap (Ready), Antar (Bring) and Jaga
(Guard).
Formative research supported the design of a campaign that included nationally broadcast TV and radio spots
featuring dangdut singer Iis Dahlia, a three-part TV drama called Kembang Untuk Nur (Flowers for Nur) that
was adapted for broadcast on a van (an evolution of the popular ‘layar tancap’ approach), and specific
message placement in 90 episodes of the popular radio sinetron (soap opera) drama Lilin-lilin di Depan (The
Guiding Light).
39
Audiences in three high priority provinces (East Java, South Sulawesi and South Sumatra) were also provided
brochures and stickers, interpersonal training materials for service providers, and some mass communication
materials like hats, pins and t-shirts were produced, and community mobilization activities.
Each of the four elements of SIAGA had different target audiences with specific behaviors identified as ‘siaga’
requiring different sorts of goals and tailored approaches. Despite the differences however, the campaign’s
use of design, color and ambassadors/spokespeople remained consistent throughout, establishing SIAGA as a
safe motherhood “brand”.
Suami SIAGA’s Tier One audience was lower- and middle-income husbands between the ages of 15 and 45;
Tier Two audiences included families (including wives), midwives and community leaders.
Suami SIAGA Key Messages
Three causes of delays were identified and three simple messages developed:
SIAP: be ready/prepared to accompany your wife
ANTAR: bring them to the health care provider
JAGA: stay with your wife during and after delivery
Assessment
Post campaign research indicates:
- Significant campaign exposure amongst target audiences
- Significant participation by key target audiences in local activities
- Significant message comprehension
- Significant changes in perceived support from husbands, community, and health services.
A 2004 review of the Suami Siaga campaign published in the Journal of Health Communication assessed both
the knowledge gained and behavioral impacts of the outreach efforts. It reported mass media reached roughly
half the intended audience in the three target provinces. It also reported that 43 percent of husbands who
were exposed to TV, radio and print elements of the campaign reported taking actions to become more
“SIAGA”.
More significantly, it drew a direct line between the frequency of exposure to the campaign and discussion
about its content, and an increased investment in being an ‘alert husband’. The findings suggest that when
husbands were exposed to multi-media campaign messages about maternal mortality prevention and birth
preparedness, men's knowledge increased and men's action toward becoming an alert husband increased, and
that the odds of knowledge acquisition and taking action were even higher for men who engaged in
interpersonal communication about the campaign messages.24
In a follow-up survey several years later, two-thirds of respondents reported they were exposed to the Suami
Siaga campaign – this is noteworthy because the survey was carried out several years after this first element of
the SIAGA package had ended.
24 Shefner-Rogers, C. L., & Sood, S. (2004). Involving Husbands in Safe Motherhood: Effects of the SUAMI SIAGA campaign in Indonesia. Journal of Health Communication, 9, 233-258
40
Lessons Learned
Talking to contemporaries about messages being delivered through mass media/edutainment appears to lead
to quantifiable behavior change, so investments in broadcast outreach should be paired with efforts to
encourage discussion about those messages/themes.
BRIEF SUMMARY OF SUAMI SIAGA PROGRAM “SPIN-OFFS”
Warga Siaga (Alert Community) Campaign
Launched in November 2001, Warga Siaga encourages all community members to be alert and prepared for
childbirth by doing their part in arranging for transport, funds, blood donations, and ability to recognize danger
signs.
Messages:
a. Alert community members are prepared to help pregnant women.
b. Alert community members are prepared to bring a birthing mother to a professional health care provider.
c. Alert community members are ready to accompany a birthing mother during childbirth.
d. Alert community members will encourage the birthing mother’s husband to be active and present during
pregnancy and childbirth.
e. Alert community members will help set up a fund for birthing mothers.
Bidan Siaga Campaign
Launched in March 2002, Bidan Siaga (Alert Midwives) promotes the midwife as a skilled (professional) and
friendly provider during pregnancy, childbirth, and the postpartum period.
Messages:
a. Midwives are friendly and easy to reach.
b. Midwives are ready to give help any time.
c. Midwives encourage the family and neighbors to be active in helping birthing mothers.
d. Midwives will take the birthing mother to the nearest health facility when required.
e. Midwives can provide referrals to the nearest health facility should an emergency arise.
f. Midwives ensure service quality.
g. Midwives can handle birthing issues without a referral.
h. Midwives are equipped with the basic necessities.
Desa Siaga Campaign
The Desa Siaga (Alert Village) campaign encourages villages to actively support birthing mothers by creating
notification chains, preparing transport, allocating village funds, and ensuring availability of blood donors. As a
result of the decentralization movement in Indonesia, control of resources had devolved to communities and
in the 55 focused villages Desa SIAGA helped to rebuild the community help system. The Desa SIAGA program
relies on the development of a fairly complex community mobilization system and the success for the program
varied in accordance with the resources available in each village.
41
NATIONAL VITAMIN A SUPPLEMENTATION PROGRAM
Program Implementer Helen Keller International & MoH with USAID funding
Program duration 1999-2005
Program goal Increase Vitamin A coverage among under-fives nationally
Introduction to National Vitamin A Supplementation Program
This case study touches on the social marketing campaign that ran between the years 2000-2004, and a
subsequent capacity building exercise for Vitamin A promotion for provincial and district health officers. The
former succeeded in increasing Vitamin A coverage in rural and urban areas to the national target of 80
percent and increasing mothers’ awareness of the benefits of Vitamin A.
The latter, which grew out of the decentralization of health services in the post-Suharto era, provided selected
districts with training and tools to conduct situational analyses and promotional campaigns advocating local
parliamentary support for supplementation programs.
One consequence of the Asian Economic Crisis was that many poor Indonesians were forced to reduce their
consumption of relatively expensive enriched foodstuffs with less expensive, less nutritious fare.
In response, HKI in collaboration with the MoH and local universities increased nutritional surveillance to
assess the scope and scale of the problem. The Nutrition and Health Surveillance System (NSS) – a household-
level quarterly surveillance activity - eventually expanded to eight rural provincial sites and four urban-poor
sites with the support of USAID, supplementing bridge funding provided by UNICEF and the ADB. The
information it generated on a range of health and nutrition indicators guided policy and program decision-
making. The NSS revealed the decline in the population’s micro-nutrient status – particularly among urban
dwellers – and provided the context and justification for the ensuing national social marketing campaign and
capacity-building initiatives.
Picture 5. Map of Vitamin A Promotion Activities
The analysis of NSS data also ensured the social marketing component of the project was properly targeted
and evaluated.
42
Social Marketing Campaign
The first phase of the social marketing campaign targeted the urban poor identified as a priority by the NSS.
Awareness raising efforts focused on the distribution of materials promoting a three-part supplementation
program in Jakarta, Semarang, Surabaya and Makassar, and a paying for airtime for a PSA about vitamin
supplementation prior to and during the third campaign month. Efforts to extend measles immunization
successfully piggy-backed on this program, reaching 100,000 children and fostering later linkages in NTB and
Sumatra.
Promotional activities took place on six different cycles ahead of the supplementation campaign months.
Messaging regarding the benefits of Vitamin A and information about when and where children could receive
it for free was standardized in all print and broadcast materials produced for the social marketing campaign.
This included the color schemes, radio and TV jingles etc, and a cartoon illustration of a baby “to create a
coherent set of materials with a clearly identifiable brand image…”
Picture 6. Vitamin A Poster
(Source: Summary of Accomplishments of the HKI/GOI Collaboration for Vitamin A, 1999-2005)
Supporting materials included posters, stickers, and banners in a variety of sizes, a calendar and brochures
with more detailed information about Vitamin A supplementation, all with a simple, direct campaign slogan of
“My Eyes are Healthy and My Body is Strong because of Vitamin A Capsules” (Mataku Sehat, Tubuhku Kuat
karena Kapsul Vitamin A). Other communications materials included key chains, caps and balloons were also
produced in limited numbers for special events.
Production and distribution of cost-effective communication materials on a national scale is a major challenge
in Indonesia. HKI selected the puskesmas network as the key distribution point for campaign materials because
it represents the lowest level of the health services chain that could be accessed by the postal system. The
puskesmas were then responsible for ensuring the timely delivery of materials to the posyandu in their
43
catchment areas. Between August 2001 and February 2005, packages of printed materials were distributed to
every province, district and puskesmas in the country. Roughly 30 percent of the district health offices and 25
percent of the puskesmas responded to a direct mail survey that, among other things solicited information
based on personal experiences about the most effective types of media to use in local health promotions, and
the constraints promotional ventures faced.
In addition to printed materials, the project produced a 30-second television advertisement with 15- and five-
second cut-downs featuring positive images of healthy children and the capsules being distributed. Broadcast
schedule began roughly one month prior to the distribution month. Channels were selected based on feedback
about women’s favored channels collected by the NSS. In addition to television-based advertisement the
project employed a well-known radio personality to voice a commercial that was translated into three local
languages in target areas and distributed to 900 stations with a request from the Ministry of Health that it be
aired free of charge as a public service announcement.
The Ministry of Health was also key in spreading the message by making all print and broadcast campaign
materials available free of charge through a website they managed or HKI’s own website. Together with HKI
the Ministry of Health was also key in organizing a media workshop in Jakarta in 2003 and sponsored a
journalism writing competition that resulted in 100 stories about “Vitamin A and child survival” being
published in newspapers around the country.
Additional advocacy efforts targeting decision-makers were also launched including a radio documentary
produced in collaboration with the American media development agency Internews that aired on 150 stations,
a collaboration with a TV show that resulted in an hour-long documentary on the supplementation program.
Capacity Building for Vitamin A Promotion
The goal of this effort was to build the capacity of local institution in 20 districts in nine provinces to promote
the use of Vitamin A. The specific goals relevant to the current context were:
Provide MOH staff, CLOs and others the tools and knowledge to adapt/implement a mass media
campaign promoting Vitamin A.
Increase capacity of journalists to produce accurate and relevant news about Vitamin A deficiencies
and steps being taken to deal with it.
Three regional socialization meetings to detail the efforts of the social marketing campaign were organized,
bringing together MOH staff, non-governmental partners like World Vision International, UNICEF and Catholic
Relief Services, journalists and program partner Kimia Farma, a leading Indonesian pharmaceutical company.
HKI engaged government experts, academics and others to work with health staff from each province over
three months to develop an informed situational analysis of Vitamin A deficiency that underpinned a 15-
minute presentation and one-page fact sheet used in formal advocacy meetings to convince local leaders to
support the supplementation program.
A 15-minute advocacy video that outlined the issue and what is being done about it was shot in three
provinces and distributed to every district and provincial health office in the country. In addition to MOH,
members of the Parliamentary Forum for Heath provided technical support. The head of the Forum would
later serve as a keynote speaker at a one-day advocacy workshop in Jakarta.
Health officials in each target district received the complete “toolbox” of materials produced for the social
marketing campaign and training on how to use it. Among the items in the tool kit was a CD with all the files
needed to replicate the materials in local languages and employing locally-relevant design elements, while
maintaining a standard national brand images and messages detailed in the earlier SM section.
44
Other initiatives included production of a how-to ‘edutainment’ manual, explaining how to plan events,
engage sponsors, strike an organizing committee etc. HKI booths appeared at a variety of special events, and a
poster design competition was organized for participating district and provincial health offices to encourage
use of the toolbox.
Assessment
The evaluation of the social marketing efforts was based on NSS data. During the campaign period the Vitamin
A coverage in rural and urban areas increased and exceeded the national target of 80 percent through
February 2003. The NSS also collected information on mothers’ exposure to the campaign materials and
messages, and mothers’ knowledge of vitamin A and the vitamin A supplementation program. Analyzing all of
these factors together, a clear association was demonstrated between mothers’ exposure to the campaign,
knowledge of vitamin A, and their children’s receipt of vitamin A.
It also documented household Vitamin A intake, established that it was below national recommended daily
allowance (RDA), proving supplementation efforts remain a critical element of the effort to reduce Vitamin A
deficiencies. The identification of low coverage among post-partum women resulted in a collaboration
between the Ministry of Health and UNICEF.
The capacity building efforts were considered a success. The district-level workshops were found to be useful
in improving annual coverage audits and linking issues like child mortality and malnutrition to Vitamin A
deficiencies in some districts. The promotional toolboxes and related training also supported effective district-
level promotions, where resources were available. The project evaluation noted that 65 percent of target
areas secured funding from local parliament compared with just 17 percent of non-target areas.
Lessons Learned
1. Competition at the local level means securing political support is a challenge. In context of a stunting
campaign it will be important to build on established networks of local political contacts, including
parliamentarian, provincial/district health staff to leverage support.
2. Program participation was strongest in areas where social marketing efforts were supplemented by
promotions capacity building.
3. Capacity building training did not result in immediate production of materials and campaign events due to
a lack of local resources, however funding was secured for future initiatives. Investing in suitable capacity
building exercises around promotion of nutrition/stunting issues will empower local officials to secure
local funding.
45
ANNEX II. LIST OF INDONESIAN PROGRAMS REVIEWED
No Year Project Name Organization Areas
Project
Budget Communication Strategy Lessons Learned
1 1988
-
1998
Lingkaran Biru (Blue Circle).
Family Planning Campaign
aimed to improve the
overall health of
Indonesian citizens by
addressing the threat that
over-population posed to
economic progress.
BKKBN, USAID National
campaign
Information
not
available.
1. Reaching rural areas with grassroots messages
and person-to-person contact.
Methods: introduce contraceptive use through
broad outreach and community participation at
the village level. The rural family planning
personnel typically would make home visits to
discuss family planning methods, provide
counseling, and make referrals to community
health centers.
Community engagement: using the combination of
field workers, health providers including village
based midwives, community based volunteers and
religious leadership (NU, Muhammadiyah and its
woman's organization Aisyiyah).
2. Promoting smaller families as a new social norm,
using social marketing
campaign through posters, billboards, public
service announcement on radio & television, wall
markers, mobile vans.
Campaign slogan: Dua Anak Cukup: Two Children is
Enough.
Campaign messages: Small, happy and prosperous
family.
1. Blue Circle found the Association of Midwives was able
to implement a highly successful training program with
project technical assistance despite the fact the
organization relied mainly on volunteers.
2. There are three elements necessary to the success and
sustainability of contraceptive social marketing:
affordable and accessible products, quality providers and
products, and effective promotion.
3. Without mass media promotion, the private sector
share of the contraceptives market would not have more
than doubled.
4. Surveys reveal the social marketing was one of the
most successful project interventions.
5. A significant number of rural couples are willing to pay
full or partially for quality contraceptive products and the
BKKBN has demonstrated that it can organize and
implement massive training programs with only limited
donor technical inputs.
6. Religious, programmatic, and political sensitivities may
have contributed to voluntary sterilization not gaining
traction.
7. 75 percent of respondents stated the best way to reach
out to target audiences was through Television.
46
2 2000-
2004
Vitamin A - Social
Marketing Campaign
Ministry of
Health, Helen
Keller
International,
USAID
Pilots in
Jakarta,
Semarang,
Surabaya
and
Makassar
scaled up
to National
Campaign
Information
not
available.
1. National promotion cycles ahead of each
of six vitamin distribution months.
Paid for TV spots developed by MoH and
UNICEF around posyandu revitalization.
30-, 15- and 5-second TV spots; 60-sec
radio spot
2. Secure rights to popular children’s song
“Dua Mata Saya…” re-versed as jingle in
TV & Radio spots; becomes focus of
children’s song competitions etc.
3. Radio PSAs: developed with recognized
“personality”, repeats key messages.
Recorded in BI, and in the Minang (West
Sumatra), Maduran (Madura/E Java) and
Sasak (Lombok) languages. Sent 900
stations with MoH appeal for free
broadcast.
4. All printed and broadcast materials
available on-line via Indonesia Nutrition
Network.
5. Range of printed materials (posters,
banners calendars, brochures) and
limited materials t-shirts, hats, key chains
etc for special events.
6. Limited sponsorships and outreach mass
events
7. Strategic partnership with NGO produces
‘edutainment’ events and later a
guidebook to the same
A clear association was seen between mothers’ exposure
to social marketing efforts, their knowledge of the
benefits of vitamin A, and their children’s receipt of
vitamin A.
Competition at the local level means securing political
support is a challenge. In context of a stunting campaign it
will be important to build on established networks of local
political contacts, including parliamentarian,
provincial/district health staff to leverage support.
Program participation was strongest in areas where social
marketing efforts were supplemented by promotions
capacity building.
Capacity building training did not result in immediate
production of materials and campaign events due to a lack
of local resources, however funding was secured for
future initiatives. Investing in suitable capacity building
exercises around promotion of nutrition/stunting issues
will empower local officials to secure local funding.
47
3 1999-
2001
Suami SIAGA (Alert
husband). The campaign
promoted desirable
behaviors that husbands
should practice to reduce
delays in pregnant women
deciding to seek care,
reaching care, and
receiving care.
Ministry of
Health, Ministry
of Women's
Empowerment
and Child
Protection,
UNFPA, John
Hopkins
University
Centre for
Communication
Programs.
Area: East
Java, South
Sumatra,
South
Sulawesi.
Target age:
15 - 45
Project
budget:
$750,000
1. National PR events, Television & radio spots
featuring dangdut singer Lis Dahlia.
2. Interpersonal communication and counseling
(IPC/C) including one-day trainings for midwives.
3. Three-part television drama Kembang Untuk
Nur (Flowers for Nur).
4.Local mobilization events.
5.Mini-grants to the community.
6.Tie-ins to existing activities - Kembang Untuk Nur
edited for mobile van usage.
1. Can successfully promote accessing professional health
care but services must be available.
4. Link between midwives and Traditional Birth
Attendants (TBAs) is still weak.
2. Need better coordination at the field level.
3. Quality of services in some areas needs improvement.
4. Expectations are low so generating enthusiasm can be
challenging.
4 1999-
2005
National TB Control
Programme. The
campaign was aimed to
Increase Directly
Observed Therapy (DOT)
for the Treatment of
Tuberculosis
Indonesian
government
with technical
partners WHO,
KNVC, and
financial
partners
GFATM, USAID,
CIDA, KNVC.
Informatio
n not
available.
Information
not
available.
Advocacy, Communication & Social Mobilization
Strategy Indonesia.
1. The communications component lacked suitable tools.
Hiring local individuals as communications implementers
was not effective because they lacked the knowledge and
interest to fill the role.
2. The Treatment Observers (community-based groups)
had to be better mobilized and trained in communications
techniques.
3. Dedicated human resources were needed to support
the communications initiative.
4. Faced Social challenges in addition to political
challenges (as national elections were held during the
campaign).
5. Must realize Healthcare provider capacity (not just
Service Delivery System but also in additional tasks).
6. Patients had to be more informed about treatment and
‘next steps’ information.
7. Treatment follow-up had to be linked to ensure
patients did not stop treatment.
48
5 March
02 - ?
Bidan SIAGA.
The campaign was aimed
at promoting the midwife
as a skilled and friendly
provider during
pregnancy, childbirth, and
the postpartum period.
Ministry of
Health, Ministry
of Women's
Empowerment
and Child
Protection, John
Hopkins
University
Centre for
Communication
Programs.
Information
not
available.
1. Promoted midwife services through radio and
television messages featuring dangdut singer Lis
Dahlia.
2. Interpersonal communication and counseling
(IPC/C) one-day training for midwives.
3. A series of 39 radio vignettes called 'Radio
Sahabat Bidan' (Friendly Midwife Radio), which
lasted 7-10 minutes designed to entertain and
educate.
TBA
6 2001-
2004
Desa SIAGA. The
campaign goal was to
encouraged villages to
become involved in safe
motherhood.
Ministry of
Health, Ministry
of Women's
Empowerment
and Child
Protection, John
Hopkins
University
Centre for
Communication
Programs.
Banten,
West Java,
Information
not
available.
1. Participative learning and action (PLA) with
involvement of local inhabitants, local leaders,
local government and village facilitators. The PLA
used games, group work activities and sharing
experiences. Facilitator was not a government
officer but someone specifically trained in PLA
methods.
1. The health professionals could not work alone.
2. Greater community involvement needed.
3. Greater participation from private/other stakeholders
was needed, as was broader local political buy-in.
Results:
83 percent of respondents who reported their village was
a Desa SIAGA indicated that they had been involved and
almost half reported discussing Desa SIAGA schemes
within their social networks. In addition, husbands and
wives exposed to Desa SIAGA were significantly, more
likely to display higher levels of knowledge of danger signs
compared to those not exposed, and deliver at a health
facility or with a midwife.
49
7 2003 -
2008
Positive Deviance / Hearth
Indonesia aka PD/Hearth
aka pos gizi. Introduced
local positive deviance
practices to families of
malnourished children to
assist with the
recuperation of the
malnourished child, help
families sustain the child’s
improved nutritional
status and prevent future
malnutrition by
supporting permanent
adoption of new
behaviors by families in
the community.
USAID, CARE,
Mercy Corps,
Ministry of
Health, Save The
Children,
University of
Indonesia,
World Vision
International.
Aceh,
Medan,
West
Sumatra ,
selected
locations in
West Java,
Malang &
Surabaya,
East Java,
Kalimantan
and Papua
Information
not
available.
Village-level PD activities and education sessions
focusing on active feeding practices and
frequencies, menu variations etc. with mothers
lead by trained local kadres.
1. There was a direct association between broad, effective
community participation and the success of the pos gizi
approach.
2. Sustainability is still a challenge as researchers did not
meet any kadres (local volunteers) implementing pos gizi
on their own without support of an NGO or DHO.
3. In terms of administrative challenges, working out the
budgeting and formal agreements between multiple
agencies was time-consuming and sufficient time must be
set aside to address this challenge.
4. Staff with advanced skills in quantitative analysis are
critical to checking the assumptions and initial analysis of
the local statistician.
5. There is a challenge getting data from the field to the
lead evaluator in a timely manner.
50
8 2004 -
2008
PVO Child Survival and
Health Grants Program.
The campaign aimed to
improve health and
reduce mothers and their
infant mortality rates in
Timor Leste.
USAID, GH,
HIDN, NUT
Timor Leste USAID
funding: $1,
500, 000;
PVO match:
$ 509, 600
1. Support MOH in improving the quality of and
access to antenatal and postnatal/newborn care
services.
2. Increasing appropriate home care and care-
seeking practices for maternal and newborn care
by mothers and other community members.
3. Café Timor Cooperative Health Services will
partner in the effort to expand improved services
to the population;.
4. Church-based groups, particularly a broad range
of Catholic-supported clinics, have been invited o
participate.
5. Included a broad network of local and
international NGOs program partners at the
district level, including: WHO, UNICEF, UNFPA.
1. The use of locally relevant mass media was an effective
vehicle for health promotions at the village level.
2. Need to realistically involve all relevant groups working
in program districts to participate in the design and
implementation of activities tailored to the needs of each
district or community.
3. Community and religious organizations, and NGOs were
key in supporting training.
4. Traditional leaders, healers and birth attendants must
play a central role in community-level program
development and program implementation.
5. Full buy-in and commitment from program staff active
in the Maternal and Child Health Working Group
(MCHWG) is needed.
6. Efforts were affected by the lack of coordination of all
district-level stakeholders in health, and the limited
number of staff in the Maternal and Child Health
Department.
9 2005 -
2010
Aman Tirta: The project
aimed to ensure
widespread access to an
affordable water
treatment product (Air
RahMat) for low income
families with children less
than five years of age. The
project relied on a public-
private partnership (PPP)
model to create the first
fully-sustainable
commercial model for
safe water systems.
Ministry of
Health, CARE
International
Indonesia, PT
Tanshia
Consumer
Products and
Ultra Salur, with
John Hopkins
University
Centre for
Communication
Programs.
Informatio
n not
available.
Information
not
available.
Information not available. 1. Behavior change towards the use of clean water was
slower than expected.
2. Sales projections for the clean water product were
lower than expected.
Key lesson learned: Critical to ensure key messages
resonate with target audiences. Follow-up surveys
revealed the target audience did not adopt or buy the
product because:
• 64 percent: did not believe it (credibility)
• 31 percent: said did not have access to it
• 12 percent stated they were satisfied with boiling water.
51
10 Mid
2005
BASIC III - The project
provided technical
support to the Ministry of
Health to expand
effective, proven newborn
and child health
interventions throughout
Timor Leste. Core
interventions included
malaria prevention,
nutrition and
micronutrient care,
Integrated Management
of Childhood Illnesses
(IMCI), Essential Newborn
Care, Healthy Timing and
Spacing of Pregnancy, and
immunization for vaccine-
preventable childhood
diseases.
USAID/BASICS
and
IMMUNIZATION
BASICS were
jointly
implemented
Timor-Leste
Asistensia
Integradu Saude
(TAIS or Timor-
Leste Integrated
Maternal and
Child Health
Care Project).
Timor
Leste.
Information
not
available.
The program was focused on creating behavior
change for policy developers (advocacy).
Information not available.
52
11 2006-
2009
SISKES
The campaign aimed to
strengthen the
Decentralization of Health
Care Systems in Alor.
Nusa Tenggara Barat
GTZ, Ministry of
Health,
Provincial and
District Health
Offices.
NTT & NTB 10,150,000
Euro
1. Must account for Indonesian government
planning and budgeting cycles;
2. Forums for coordination of donors at province
level, developed in both NTT and NTB are fully
owned by Indonesian Partners through the PHO in
NTT and The Provincial Planning Board (BAPPEDA)
in NTB.
3. Analysis of district and health account
expenditures was introduced in all ten NTB
districts to improved planning and budgeting, and
to promote public expenditure transparency;
4. SISKES supported improvement of the health
management Information System through local
Provincial Health Offices (PHOs) and District Health
Offices (DHOs) in both provinces.
1. Essential social norms and practices were researched
and integrated into the campaign.
2. Effective process for identifying local Key Opinion
Formers especially religious community.
3. Local campaign materials must be simple and reflect
local people, custom etc.
4. Relationships must be developed and strengthened
throughout the life of the project.
5. Campaign succeeded because of buy-in from the Head
of Dinas Kesehatan (Health Services).
53
12 2006 -
2010
Community Based Avian
Influenza Control Project
(CBAIC). USAID and
Indonesia’s strategy for
reducing the risk of avian
flu. The goals of CBAIC
included prevention of
H5N1 avian influenza and
the building the
Indonesian government’s
capacities.
USAID
implemented by
Development
Alternatives,
Inc. (DAI). The
Johns Hopkins
CCP designed
and
implemented
behavior change
communications
(BCC) strategy.
Nine
Provinces
in Western
Indonesia
Information
not
available.
Project began with intensive three-month
campaign: Several mutually reinforcing elements
(e.g. common messaging/look/branding, etc.)
integrated in campaigns across mass media,
distribution of printed materials and community-
level events, and supports consumer recognition.
Two clear, focal messages re: risk reduction anchor
all on-air (TV PSAs) and TV and radio broadcast
fillers and print materials including stickers,
posters, standing banners, booklets etc.
TV celebrity served as ambassador linking
broadcast & non-broadcast elements like local AI-
themes variety shows in target areas.
Additional items:
Government spokesperson training focuses
messaging.
Community mobilization develops volunteer base,
promotes surveillance, produces flip-charts,
training booklets etc.
Newsletter with basic interactive element –
readers send short message service responses to
quizzes.
Bus seat-covers bearing AI messaging alert
travelers and enlist them to spread messages to
home villages.
1. Quantitative and qualitative research showed the short
intensive mass media campaign was successful in
promoting key behaviors, reinforcing messages that were
also delivered directly to the community level;
2. A cost-benefit analysis found that an investment of US$
1.10 per household per message could affect positive
behavior change to reduce the risk of AI transmission.
Results:
Intensive three-month mass media campaign aired 3,408
TV spots and 34,991 radio spots reaching 96 percent (159
million viewers) of the targeted audience;
CBAIC radio content reached an estimated 31 million
listeners nationwide
54
13 2007-
2008
WASH (Water, Sanitation
and Hygiene) in schools.
The campaign aimed to
improve water and
sanitation processes and
thus reduce acute
diarrheal and other
WASH-related diseases
among school children.
Kementerian
Kesehatan,
UNICEF, John
Hopkins
University
Centre for
Communication
Programs.
Area: 60
schools in
Banda
Aceh and
Aceh Besar
District.
Information
not
available.
1. Conducted a training of trainers for NGO/CBO
partners agencies and education, and religious
affairs government staff (provincial and district).
Publication and project materials: Activity book,
story book, monitoring book, “Snakes & Ladders-
style” ladder children's game, puzzle, booklet,
flipchart, posters and stickers.
2. Collected and analyzed baseline data through a
knowledge, Knowledge, Attitudes and Practices
(KAP) survey on hygiene and sanitation;
3. Develop hygiene curriculum and manual for
target schools;
4. Trained teachers and students on software and
participatory monitoring, planned and conducted
school and community level promotional campaign
activities, including a road show; created school-
community committees to develop action plans on
water safety and hygiene;
5. Develop a maintenance manual and training
workshops.
1. Creating a strong supportive environment with
government is important;
3. Identifying and field-testing messages and channels is a
priority;
4. ID suitable Key Opinion Formers to influence and
support behavior change;
5. A campaign or social-marketing approach is suitable for
promoting one specific hygiene practice such as washing
hands with soap.
6. A campaign need not always be organized at a national
level. It can be delivered effectively to a smaller target
population at the district level;
6. To stimulate improvements in several hygiene
practices, use participatory methods. For BC, focus not on
messages but an active understanding of high risk
behaviors and good practices;
7. BC techniques such as PHAST (Participatory Hygiene
and Sanitation Transformation) must be adapted to the
local environment and context.
8. When working in schools, need to be sensitive about
addressing the issue of menstrual hygiene management;
9. Monitoring and evaluation should be participatory and
directly involve the community.
55
14 2007-
2009
Indonesia Immunization
Project - Lima Imunisasi
Dasar Lengkap (LIL).
Project goal was to
improve child health and
boost immunization rates.
USAID, BASICS,
Ministry of
Health, Province
and District
Government
Health Services.
Area: 68
districts in
seven
provinces
(DKI
Jakarta,
Banten,
West Java,
Central
Java, East
Java, South
Sulawesi
and North
Sumatra).
Information
not
available.
Campaign materials and approaches:
1. Radio and TV PSAs ran from Sept ‘08 - Mar 09.
TV talk shows with local leaders targeted specific
populations and increased local commitment.
2. Printed leaflets showing the immunization
schedule, the benefits of each vaccine, and other
simple messages for distribution by kadres as part
of community outreach activities; 3. Distributed
posters for Puskesmas and standing banners for
Posyandu with standard messaging for the
community.
4. School-based materials developed by Pramuka
(Indonesian scouts) and faith-based promotional
materials used by Muslimat NU and 'Aisyiyah
initiatives such as Alim Ulama endorsement and
Quran readings in mosques reinforced the
messages.
5. Erected billboards in all campaign districts and
provincial capitals with messages that would recall
TV and print messages.
6. National and provincial close-out workshops
provided a final opportunity to share program
activities and recognize the newly expanded role
of partner organizations to increase and maintain
immunization coverage.
1. Indonesia’s established national immunization program
requires sustained advocacy especially at the district level.
2. Respected and widely established community, religious
and professional organizations can be recruited to be
effective 'demand side' partners for social mobilization,
local program monitoring and advocacy.
3. Strategically recruited local partners can succeed in
overcoming resistance to the desired action and
outcomes in particular area. Local religious and ethnic
groups were important partners in several areas - Muslim
leaders in Madura and parts of East Java, Chinese
community leaders in Medan city etc.
4. In the era of decentralization, local champions may be
more effective than national figures in advocating to local
government.
5. Restricting funding to a limited number of districts and
puskesmas in a province was seen as a weakness by some
of the provincial team leaders. All effort should be made
to offer support to the broader catchment area depending
on their needs.
6. Focused use of mass media, particularly television, can
establish a catchy phrase such as 'L-I-L' that will continue
to remind the public of the importance of complete
vaccination of infants long after this campaign ends.
56
15 2007-
presen
t
PNPM Generasi - Uses
incentivized block grants
to target three
Millennium Development
Goals lagging in Indonesia:
maternal and child health
and universal primary
education.
Bappenas,
Coordinating
Ministry for
People’s
Welfare,
Ministry of
Finance, PNPM
Support Facility
Joint
Management
Committee:
World Bank,
AusAid, Danida,
DFID, the
Embassy of the
Netherlands,
the European
Union & USAID
2,900
villages in
eight
provinces:
West Java,
East Java,
North
Sulawesi,
Gorontalo,
East Nusa
Tenggara,
West Nusa
Tenggara,
Maluku
and West
Sulawesi
US$120
million
(2010-2012)
Elements of broad outreach and education
strategy developed by project contractor were
produced, primarily posters, flip-charts and other
tools to support trainings and outreach.
1. Broad field testing for materials prior to dissemination
is required.
2. It is important that target audiences “see themselves”
in outreach materials: images, language, dress and other
social attributes must be relevant to the target audiences;
either customize to location or aim for generic
representations.
3. Centralized production of all campaign materials
simplifies procurement but adds to costs as materials will
often be transported long distances; decentralizing
production may save money.
4. Future efforts must consider whether existing human
resources attached to PNPM are the best vehicles for
effective behavior change communications efforts.
5.Identification of district-level communications
specialists to serve as mentors and/or implementers in
the field will enhance engagement efforts.
57
16 Jun
08-
Dec 10
Prima Bina - The
campaign promoted
proper Infant and Young
Child Feeding (IYFC)
practices in the target
communities.
CARE Indonesia Area: West
Timor, NTT
Project
budget: US$
751,076
1. Capacity building of village midwives on
breastfeeding counseling;
2. Trained health workers, mostly midwives and
traditional birth attendant, as breastfeeding
counselors;
3. A Key informant interviews (KII) with six
midwives and 1 nurse at each Polindes;
4. Social mapping through FGD with pregnant and
lactating women, fathers and grandmothers;
5. Engagement with local health officials.
1. The idea of a midwives sitting down and counseling
new mothers is a foreign concept and resulting in one-way
communications;
2. Important to map and account for local
languages/dialects and fluencies. In West Timor villages,
Dawan is spoken. In TTU, it is Tetun and Belu. The
midwives however, are fluent in Bahasa Indonesia which
is not the local language.
3. Geography also affected the program as accessibility in
mountainous regions was very difficult, impacting efforts
to reach patients;
4. Culturally a woman will seek out her mother or mother-
in-law rather than a midwife for advice;
5. Midwives frequently mentioned low levels of education
as a barrier;
5. It is important to involve fathers and grandmothers in
the process.
17 One
Year
Fantastic Mom. Project
goal: Increase the correct
practice of hand washing
with soap to reduce infant
mortality from diarrhea.
USAID, KUIS,
John Hopkins
CCP, Save the
Children,
Muhammadiyah
, UI, UNICEF,
The World Bank,
Ogilvy PR
Informatio
n not
available.
Information
not
available.
1. Research-based effort to turn hand-washing
with soap into a social movement by empowering
women to believe that the solution was in their
hands.
2. Recruitment of community leaders, NGOs, the
media and faith-based organizations to support
community mobilization efforts and be the
message bearers.
3. Road shows employing local celebrities reached
200 communities and radio programs on 13
stations extended the outreach efforts. Late in the
campaign national-level “festivals” were also
organized. Ten million people reached by
community mobilization and media campaign.
4. Private-sector partnership with Unilever led
campaign messaging to be included in their soap-
product campaigns.
With the support of the government, media and private
sector partners, the campaign’s “Hand Washing with Soap
Movement,” reached 10 million people.
Post-campaign assessment concluded:
• Awareness of the benefits of hand washing with soap
rose from 45 percent to 85 percent among the targeted
audiences
• knowledge about how to wash their hands properly
increased from 55 percent to 63 percent
• the practice of hand washing with soap rose from 35
percent to 56 percent.
Lessons
1. Quality marketing campaign essential
2. Strong public/private partnerships are vital to success
3. Limits of social marketing-cannot overcome structural
and systemic issues
58
18 2011-
2014
High Five ("High 5")
Kelurahan - Project goal is
to improve hygiene and
sanitation practices at the
household and
community levels in urban
areas with high diarrhea
prevalence.
USAID in
cooperation
with Cipta Cara
Padu
Foundation
12,000
households
in Medan,
Surabaya
and
Makassar,
20 villages
and 20
schools.
Information
not
available.
To generate demand for improved water and
sanitation facilities, the project will focus on
community mobilization, public-private
partnerships, and communications campaigns;
Role of women seen as central to promoting
behavior change related to sanitation practices.
The local media engagement in disseminating
information on better hygiene practices will be
leverage through community-based discussion
forums.
TBA
19 2009-
2013
Australia and Indonesia
Partnership for Maternal
and NeoNatal (AIPMNH).
The project is aimed to
help strengthen the
monitoring and evaluation
capacity of government
agencies and provide
nurses and midwives
training in comprehensive
emergency obstetric
neonatal care and
emergency first aid.
Coffey Int'l
Development,
Ministry of
Health,
Bappenas, NTT
Bappeda, NTT
Provincial
Health office,
Family Planning
Agency
Area: 14
districts in
NTT.
Project
budget:
$32,306,744
1. Workshops for Government partners at national
level;
2. Data Collecting through interviews with partners
at national level;
3. Trainings for midwives through AIPMNH's sister
hospital program, a partnership where a team of
health workers from national renowned hospitals
are contracted to provide on-the-job training to
staff in six districts hospitals throughout NTT.
4. Supporting information materials in local
languages.
1. Language barriers are a challenge - local communities
prefer to use their own language or dialect;
2. Geographic distance between different locations.
3. Lack of local capacity (Kupang) to produce suitable
quality printer materials means all supporting attributes
must be produced in Java or Bali.
59
ANNEX III. LIST OF INTERVIEWEES MCI (November, 2012)
Bappenas (postponed until further notice)
Ministry of Health – various directorates (December 2012 – January 2013)
PSF (February 22, 2013)
UNICEF (November 30, 2012)
The Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHIPEGO Jakarta)
GAIN
Australia Indonesia Partnership for Maternal and Neonatal Health
World Food Programme
Helen Keller International
Save the Children
Savica Consultancy
London School of Hygiene and Tropical Medicine
The World Bank
Center for Evaluation Research at Johns Hopkins Bloomberg School of Public Health
Three account managers from Jakarta PR firms (requested anonymity)
60
ANNEX IV. STEPS IN COMMUNICATION FOR
BEHAVIOR CHANGE
World Bank Project Phases
Steps in Communication for Behavior Change Estimated Range of Time
Project Identification
1. Carry out communication situation analysis 2 weeks
2. Determine broad communication for behavior change objectives based on overall project goals
1-2 weeks*
3. Review existing information and analyze information gaps
4 weeks
Project Preparation
4. Complete assessment of institutional capabilities and decide on basic responsibilities
2 weeks
5. Plan and conduct initial formative research 8-24 weeks
Pre-Appraisal/ Appraisal
6. Complete initial formative research 4-24 weeks
7. Design a comprehensive behavior change strategy, including its communication component but also link to training needs, product, etc
2 weeks
Project Implementation
8. Stakeholder meetings to complete behavior change strategy
2 weeks
9. Assign responsibilities for materials preparation, training and remaining research, including monitoring and evaluation
2-4 weeks
10. Prepare message and media plans; conduct additional formative research if needed
2-4 weeks
11. Draft, pretest, and finalize messages and materials 8-16 weeks
12. Produce the communication for behavior change materials
8 weeks
13. Prepare to implement communication and other components of the behavior change strategy including training
4-8 weeks
14. Plan, conduct, and analyze a baseline survey 8-16 weeks*
15. Implement communication activities 1-4 years
16. Monitor and adjust project activities Ongoing/periodically
17. Plan and conduct an impact evaluation 8-12 weeks
Project Completion
18. Disseminate project achievements and lesson learned
*usually done simultaneously with other steps
61
ANNEX V. SAMPLE OF TERMS OF REFERENCE FOR
THE FORMATIVE RESEARCH
Terms of Reference for Research Contractor to Conduct Formative Research for the Nationwide Nutritional
Communication Campaign to Address Childhood Stunting in Indonesia
Commissioned by: Millennium Challenge Corporation - Indonesia 1. Background Although Indonesia has succeeded in combatting poverty by reducing the poverty rate of its population from 16.6% in 2007 to 12.5% in 2011, child malnutrition remains an urgent issue. Statistics indicate that 35.6% of Indonesian children suffer from stunted growth, which is defined by UNICEF as “below minus two standard deviations from median height for age of reference population”. Currently, Indonesia is number five of countries with the largest number of childhood growth stunting cases among children under the age of five. An estimated 7,688,000 Indonesian children are suffering from this condition, with over 50% living in the four provinces of East, West, and Central Java and North Sumatra. Growth stunting in a child can begin when a child is still in utero and any damage caused by poor nutrition before the age of two years is deemed irreversible. The health condition and dietary behaviours of a mother is, thus, vital in preventing growth stunting in a child. Stunting is the result of chronic and often intergenerational under-nutrition coupled with frequent illness due to various factors such as a caregiver’s lack of education, use of unsafe water, an insanitary environment and limited access to food and poverty. Stunted growth is also associated with lower cognitive development and poor productivity. Children who suffer from stunted growth often grow into adults with physical and cognitive limitations, such as high susceptibility to incommunicable diseases, low cognitive capacities that hinder employment possibilities and a tendency to have a high fertility rate. The Government of Indonesia, with support from the Millennium Challenge Corporation, will undertake a new initiative to eradicate stunting among children under the age of two years. The project will encompass activities aimed at specific improvements in the following: 1) improve maternal nutrition and decrease incidence of children born less than 2500 grams; 2) increase rates of exclusive breastfeeding among children 0-6 months old; 3) improve understanding and application of weaning and complementary feeding practices among lactating and mothers of children 7-24 months old; 4) improve sanitation conditions and household hygiene behaviours; and 5) communities and service providers enter into mutually-agreed upon contracts aimed at ensuring a connection between stunting prevention services and community activities. The project will also include a national campaign aimed at increasing public awareness of early childhood stunting as a national nutrition issue. Anecdotal information seems to suggest that the concept of child growth stunting is understood only by a small number of Indonesian health officials and nutrition experts, while many among the government bureaucracy as well as at the community-level of the general population are unfamiliar with it. Many are still unaware that the growth potential for children under the age of 5 is the same regardless of genes, ethnicity and geographic location. Thus, the challenge of designing an effective campaign on childhood stunting in Indonesia is one of introducing to the general Indonesian population an unfamiliar, albeit pressing, concept and problem and its repercussions in regard to Indonesia’s children. In line with this, a research contractor to conduct formative research, the cornerstone of a successful communication campaign, is needed to overcome this challenge and provide references to ensure the formulation of an effective childhood stunting communication campaign.
62
2. Objective of Formative Research The research contractor is expected to conduct formative research aimed to identify the key relevant issues and influencers of the campaign’s target audience through assessment of knowledge, attitudes and practices. The research should also identify factors that may predict willingness to consider and adopt new behaviour. Researchers should also identify locally-relevant “gateway moments” or “milestones”, namely key transitional points in a person’s, family’s or community’s life during which they may be receptive to information that can lead to significant behaviour change, including a first pregnancy and the birth of a first child. While household-by-household level assessments are not practical for a project of this size, trends can be identified that will help fine-tune the audience selection, inform the development of the strategy and approaches, and the production of suitable outreach materials and messages. Specific objectives of this formative research include, but are not limited to, the following:
Gain insights and record community understanding of adequate and healthy dietary habits and patterns, particularly in regions with high rates of childhood stunted growth.
Gain insights and record nutritional intake of pregnant mothers and mothers’ feeding behaviour toward their children along with their knowledge of adequate nutritional intake for their children, particularly in regions with high rates of childhood stunted growth.
Gain insights on the knowledge of health care providers regarding healthy maternal and child dietary habits and patterns and their potential roles in a public awareness campaign to address childhood growth stunting.
3. Methods The study requires the employment of both quantitative and qualitative research techniques, which may include structured observation, focus group discussions, behaviour trials and in-depth interviews, or any other scientific methods. The formative research will be conducted in X regions: (include the names of the regions here). DETAILED RESEARCH DESIGNS WILL BE PROPOSED BY THE RESEARCH CONTRACTOR AND FINALIZED IN COLLABORATION WITH
THE THE RELEVANT STAKEHOLDERS. 4. Responsibilities of Research Contractor The responsibilities of the research contractor encompass the following:
Formulation of a detailed research plan, incorporating inputs from the project’s stakeholders, specifically the Millennium Challenge Corporation – Indonesia and Government of Indonesia.
Formation of a capable research team and necessary support staff, including its recruitment, training and deployment.
Establishment, implementation and management of the research.
Organization of necessary logistics, administrative and financial matters, including those related to travel, accommodations, allowances, communications, and stationery, for the implementation of research.
Development of a database for data entry.
Assurance of quality of fieldwork, data collection and data entry.
In-depth analysis of the results of the research.
SUBMISSION OF DRAFT REPORTS AS DEEMED NECESSARY AND THE PRODUCTION OF A FINAL REPORT.
FORMULATION AND IMPLEMENTATION OF APPROPRIATE DISSEMINATION STRATEGY.
5. Qualifications and selection of research contractor
Only bids from invited agencies will be considered as research contractor for this initiative.
The research contractor will be a professional agency experienced in conducting research, particularly with experience on public sector and/or developmental issues in Indonesia.
Experience in carrying out research in the field of public health and/or nutrition in Indonesia or other developing countries would be an advantage.
63
Familiarity and understanding of Indonesia’s heterogeneous population, governmental mechanisms and logistical challenges, among others, are a must.
The research contractor will have ready a research team consisting of personnel with expertise and experience in relevant quantitative and qualitative research methods and knowledge of basic Bahasa Indonesia. Fluency in Bahasa Indonesia among the researchers would be a great advantage.
In this regard, the research contractor must include the names and curricula vitae of principal personnel in its proposal, consisting of but not limited to the following positions:
o Quantitative researcher o Qualitative researcher o Quantitative field worker o Qualitative field staff
Interested research contractors will submit a detailed proposal; including elaboration on research method, research plan, outline and schedule, research team (with CVs of principal research team members) and budget.
Identification of key sample regions for research must be included in proposal along with relevant rationale.
In order to allow effective negotiations, please ensure that a net and all inclusive budget is fully broken down to display all individual costs including salaries, travel, per diem and incentives to informants as well as include all taxes and duties.
The Indonesian Ministry of Health will play a significant role throughout the research process including, but not limited to: providing input for the technical design of research methods, monitoring data collection and review of draft reports. The active engagement of MOH officials and staff should be included in the proposal.
6. Estimated Duration of the Contract The research contractor will be engaged for a maximum period of six months, from establishment of research to the submission and dissemination of the final report. However, the research contractor should stand ready to disseminate results of this research after this period if and when it is deemed necessary. 7. Outputs The final outputs will include:
Cleaned and fully referenced electronic data sets in an agreed format with copies of the original data collection forms.
Full transcripts of all in-depth interviews and focus group discussions both in hard form and electronic format.
A presentation of main findings and results at stakeholder workshop to prepare initial draft report.
A FINAL REPORT DOCUMENT IN … COPIES WITH DETAILED FINDINGS IN ENGLISH AND BAHASA INDONESIA.
An executive summary document in English and Bahasa Indonesia in … copies, suitable for general consumption and an electronic version (in English and Bahasa Indonesia) of the executive summary document suitable for internet dissemination.
A presentation of main findings of final report to all stakeholders in Jakarta. 8. Time Schedule It is expected that the work will last a maximum of 6 months from appointment of the research contractor to final report. The firm is required to estimate a detailed work schedule for each phase as part of the technical proposal. A suggested schedule for each phase is set out in the table below:
OUTPUT DURATION
PREPARATION WEEK 1-2
SUBMISSION OF INCEPTION REPORT WITH REFINED METHODOLOGY WEEK 3
TRAINING AND FIELD WORK WEEK 4-14
ANALYSIS AND PREPARATION OF INITIAL DRAFT REPORT WEEK 15-18
SUBMISSION OF INITIAL DRAFT REPORT WEEK 19
64
WORKSHOP TO PRESENT AND DISCUSS FINDINGS WITH ALL STAKEHOLDERS WEEK 20
FINALIZATION OF REPORT WEEK 21-23
SUBMISSION AND PRESENTATION OF FINAL REPORT WEEK 24
65
ANNEX VI. SAMPLE OF TERMS OF REFERENCE FOR THE COMMUNICATION AGENCY
Terms of Reference for Communication Services Agency to conduct
Communication Campaign to Address Childhood Stunting in Indonesia
Commissioned by Millennium Challenge Corporation - Indonesia
1. Background Although Indonesia has succeeded in combatting poverty by reducing the poverty rate of its population from 16.6% in 2007 to 12.5% in 2011, child malnutrition remains an urgent issue. Statistics indicate that 35.6% of Indonesian children suffer from stunted growth, which is defined by UNICEF as “below minus two standard deviations from median height for age of reference population”. Currently, Indonesia is number five of countries with the largest number of childhood growth stunting cases among children under the age of five. An estimated 7,688,000 Indonesian children are suffering from this condition, with over 50% living in the four provinces of East, West, and Central Java and North Sumatra. Growth stunting in a child can begin when a child is still in utero and any damage caused by poor nutrition before the age of two years is deemed irreversible. The health condition and dietary behaviour of a mother is, thus, vital in preventing growth stunting in a child. Stunting is the result of chronic and often intergenerational under-nutrition coupled with frequent illness due to various factors such as a caregiver’s lack of education, use of unsafe water, an insanitary environment and limited access to food and poverty. Stunted growth is also associated with lower cognitive development and poor productivity. Children who suffer from stunted growth often grow into adults with physical and cognitive limitations, such as high susceptibility to incommunicable diseases, low cognitive capacities that hinder employment possibilities and a tendency to have a high fertility rate. The Government of Indonesia, with support from the Millennium Challenge Corporation, will undertake a new initiative to eradicate stunting among children under the age of two years. The project will encompass activities aimed at specific improvements in the following: 1) improve maternal nutrition and decrease incidence of children born less than 2500 grams; 2) increase rates of exclusive breastfeeding among children 0-6 months old; 3) improve understanding and application of weaning and complementary feeding practices among lactating and mothers of children 7-24 months old; 4) improve sanitation conditions and household hygiene behaviours; and 5) communities and service providers enter into mutually-agreed upon contracts aimed at ensuring a connection between stunting prevention services and community activities. As part of this project, Millennium Challenge Corporation - Indonesia and the Government of Indonesia plans to develop a national communication campaign aimed at increasing public awareness of early childhood stunting as a national nutrition issue. While nutritional and environmental contributors to childhood stunting have and are being addressed in Indonesia, the issue has yet to be addressed in a systemic and holistic manner. Furthermore, the concept of child growth stunting is understood only by a small number of Indonesian health officials and nutrition experts and many among the government bureaucracy as well as at the community-level of the general population are unfamiliar with it. Many are still unaware that the growth potential for children under the age of 5 is the same regardless of genes, ethnicity and geographic location. In connection with this, a formative research has been commission to pinpoint the gaps in knowledge among the general Indonesian population, as well as communities, parents of young children and health care providers, especially in regions most marked by cases of childhood growth stunting. The results of the formative are to be used as a base reference for the development of an effective public awareness campaign. Further formative research may be carried out when the need arises. 2. Objective of Public Awareness Campaign The public awareness campaign should aim to address the following issues:
66
Low Existing Levels of Awareness/Understanding: There is a fundamental lack of familiarity with the subject of stunting across critical target groups from the Ministry of Health down to the village level including entrenched misconceptions (e.g. genetics determines height-to-weight ratios) and thus has no link to the nutritional status of children.
Need for Broad Multi-Stakeholder Buy-in and: Past experience has shown that a successful stunting communications campaign requires the engagement and empowerment of multiple tiers and elements of society. Partnering with an established national program or programs will better address the government’s priorities and ensure their support.
3. Scope of Work The selected agency is expected to develop a nation-wide public awareness campaign strategy in three steps: 1) conceptual outline, 2) main components, and 3) detailed design. This public awareness campaign is to be carried out over a three-year duration, as follows:
Phase I: Year I a. Development of behaviour change strategy. b. Design and production of communication behaviour change materials (including pre-testing).
Phase II: Year II a. Launch and implementation of campaign. b. Monitor and adjust campaign activities.
Phase II: Year III a. Dissemination of project achievements and lessons learned.
Research components (i.e. formative, baseline and evaluation) of the campaign will be conducted by another party. 4. Qualifications of communication services agency The work needed to realize this national public awareness campaign is considerable and requires the expertise and capacities of a professional communication services agency. In line with this, selected agencies have been invited to apply as the agency for this endeavor and should fulfill the following requirements:
Only bids from invited agencies will be considered for selection.
The agency will be a local agency or an international firm with offices in Indonesia with experience in carrying out large-scale public awareness campaigns at the national level. Preference will be given to agencies with experience in successfully conducting similar campaigns in Indonesia.
Familiarity and understanding of Indonesia’s culture, heterogeneous population, demographics, governmental mechanisms, among others, are a must.
The agency must have understanding and awareness of the proclivities and preferences of the Indonesian general public in relation to effective mass media communications.
The agency should have familiarity and understanding of relevant Indonesian health and nutritional issues and dietary habits.
The agency will have ready a core team consisting of experienced professionals who will be in charge of this campaign and include their curricula vitae in its proposal. The professionals must possess high level of creativity and ability to accord it effectively in the context of mass communications targeted at the Indonesian general public.
The agency must have a reputation for consistently delivering high quality services as attested by references from its clients. (References are to be included in proposal.)
It should be noted that past public awareness campaigns in Indonesia have benefited greatly from the active participation of local public figures and/or celebrities in roles such as campaign ambassador and/or spokesperson. Thus, the contracted agency should be able to envision the right candidate for such roles and have the capacity to engage them in the campaign.
The agency must be able to identify key messages and formulated them as slogans or catchphrases, which will feature prominently in the campaign25.
25 Much can be learned from past successful health related public awareness campaigns in Indonesia such as the widely
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The agency must have the ability to garner large blocks of advertising time and exposure required to sustain this campaign.
5. Selection Process
Interested agencies will submit a detailed proposal; including elaboration on campaign strategy as well as its outline and work schedule, list and curricula vitae of core team members and detailed budget.
In order to allow effective negotiations, agencies should ensure that a net and all-inclusive budget is fully broken down to display all individual costs including salaries, travel, per diem and all taxes and duties.
Agencies that have passed a preliminary selection shall be invited to attend a briefing to discuss further details of the campaign.
Following the briefing, the agencies shall be invited to submit their respective proposals and subsequently present and pitch their proposals to the campaign stakeholders in a location in Jakarta.
The final selection of agency shall be conducted after consideration of the proposals and the ensuing presentations.
6. Estimated Duration of the Contract The communication services agency will be contracted for a period of three years. 7. Work Schedule It is expected that the work will last a maximum of 3 years. Potential agencies are required to provide a detailed work schedule for each phase as part of its proposal to be submitted. The overall timeline for the project is set out in the table below:
Project Phases Steps in Communication for Behavior Change
Development Phase I: (Y1)
Develop behavior change strategy, including its communication component but also link to training needs, product, etc, including pre-testing the materials.
Stakeholder meetings to inform and gain consensus on the behavior change strategy
Implementation Phase II: (Y2 – Y3)
Assign responsibilities for materials preparation, training and remaining research, including monitoring and evaluation
Produce the communication for behavior change materials
Prepare to implement communication and other components of the behavior change strategy including training
Plan, conduct, and analyze a baseline survey
Launch campaign
Implement communication activities
Monitor and adjust project activities
Evaluation Phase III Plan and conduct an impact evaluation
Completion Disseminate project achievements and lesson learned
popular “Dua Anak Cukup” (Two Children Are Enough) slogan of the Suharto-era’s highly successful family planning program
or “Empat Sehat, Lima Sempurna” (Four is healthy, Five is Perfect) slogan introducing to the Indonesian population the
composition of a nutritious meal and the benefits of milk.
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ANNEX VII. SAMPLE OF INVITATION FOR
ADVERTISING AGENCY
(Name of organization) needs Creative Agency & Media Planner Agency to help communicate health information and recommendations regarding child nutrition in a creative and engaging way. All agencies (local & international) are open to participate.
For this agencies procurement process, the agency who is willing to submit a proposal must have a broad range of activation services in Indonesia and also need to demonstrate ability to conduct a national campaign and reach target audiences in various settings.
The minimum requirements for the agency, both for the creative agency and media planner are:
a. Extensive experience in conducting national campaign, especially in getting the hard-to-reach communities.
b. Strong knowledge on consumer segmentation and insight, specifically on nutrition and food consumption pattern.
c. Familiar with public health issues
d. Creative team with strong knowledge on channel execution in conventional media (i.e. above the line and below the line) and other alternative media
e. Able to provide strong client services.
If your company can fulfill the above requirements and is interested to participate in this bidding process, please send the requirements mentioned at the attachment which have to be sent by no later than (Month) (Date), (Year) at 12 PM Jakarta local time. Late submissions will not be accepted.
Please send your documents (in hardcopy) to the address below:
Advertising Agency Bidder’s Registration (Address)
Attn. (Person in Charge)
For easy identification, the cover of the documents (including the envelopes) must be clearly named as your company’s name and marked as either 'CREATIVE AGENCY REGISTRATION' or 'MEDIA PLANNER REGISTRATION'.
Strictly no online or e-mail submission will be accepted. Please be informed that this is just a preliminary selection process and NOT an invitation to bid.
Once your company submits all of the requirements, we will send the Request for Proposal (RFP) only to those who have passed the initial selection. (Name of organization) will evaluate all the requirements and choose only 5 (five) candidates. Those 5 (five) selected agencies will be invited to present their ideas and will be expected to deliver a proposal.
For any queries regarding the requirements, please contact (Person in Charge), or send it to (Email of Person in Charge).
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ANNEX VIII. TEMPLATE OF CREATIVE BRIEF
Title of Campaign
I. Target audience: who are the main targets of the campaign? It is usually broken down into main,
secondary and tertiary target audience.
II. Communication Objectives: what are the behaviors that need to be changed?
As the result of the communications, the target audience will (put in clear behavior objectives):
- Indicator 1
- Indicator 2
III. Barriers: what are the challenges preventing the target audience from doing the behaviors that
are recommended?
IV. Key Promise: what is the “reward” for the target audience if they do the recommended
behaviors?
V. Support Statements: provide compelling supporting arguments or evidences on why target
audiences need to change their behavior.
VI. Tone / Image: provide direction regarding the visual mood and design of the communication
materials.
VII. Media: provide the types of communication tools that will be needed and developed for the
campaign.
VIII. Openings / Channels: provide the communication channels / media that will be utilized for
message dissemination.
IX. Creative Considerations: write additional information that might be relevant in the development
of the creative concepts.
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ADDITIONAL DOCUMENTS
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DOCUMENT 1 – STAKEHOLDERS CONSULTANT REPORT
1. BACKGROUND
The Millennium Challenge Corporation (MCC) was established in January 2004 through legislation from the
United States government, with the overriding objective of promoting economic growth and reducing poverty
globally. MCC signed a Compact with the Government of Indonesia in November 2011, totaling $588 million in
grants, covering three projects:
1) Community-Based Health and Nutrition to Reduce Stunting Project (Project),
2) Green Prosperity Project, and
3) Procurement Modernization Project.
The Compact’s $131.5 million CHNRS Project seeks to reduce and prevent low birth weight, childhood stunting,
and malnourishment of children in project areas. The project will target villages in six to seven provinces (to be
identified) where rates of stunting and low birth weight in infants and children up to two years old are higher
than national averages.
Currently, stunting (low height for age) affects 35.6% percent of children living in Indonesia.26 Stunting early in
life has been linked with decreased cognitive development, lowered school achievement outcomes, and
diminished productivity later in life. Improving maternal nutrition, increasing rates of breastfeeding and
improving sanitation standards have all found to have a positive effect on decreasing stunting rates in
developing countries. The Project seeks specific improvements in the following areas:
vi. Improve maternal nutrition and decreased incidence of children born less than 2500 grams
vii. Increase rates of exclusive breastfeeding among children 0-6 months old
viii. Improve understanding and application of weaning and complementary feeding practices among
lactating and mothers of children 7-24 months old
ix. Improve sanitation conditions and household hygiene behaviors
x. Communities and service providers enter into mutually-agreed upon contracts aimed at ensuring a
connection between stunting prevention services and community activities.
xi.
In an effort to address the persistent challenge of early childhood stunting in the country, Government of
Indonesia (GoI) through the support from the Millennium Challenge Corporation (MCC) will seek to undertake
a new initiative aimed at supporting demand and supply interventions to reduce stunting among 0-2 years old
children under the Program Nasional Pemberdayaan Masyarakat (PNPM) Generasi Plus.
One of the distinctive value added aspects of the program’s design is its focus on awareness raising to address
issues related to stunting prevention including maternal, child healthy, hygiene, sanitation and parental
education. To this aim, the Government of Indonesia with the support from World Bank has been tasked with
developing a situation analysis and overview of past campaigns, a communication strategy and a final Terms of
Reference (ToR) for contract bidding. The final ToR developed will be a critical tool in ensuring that potential
future bidders for implementation have access to all pertinent materials to develop strong proposals for final
considerations.
2. OBJECTIVE, SCOPE AND METHOD
In addition to the situation analysis and overview of past campaigns document, the objective of this
assessment in conducting the stakeholders consultation is to explore the wide range of approaches and
26 National estimate based on RISKESAS 2010 data
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feedback on awareness-raising and behavior change, including those lessons learned which can be drawn upon
during the formulation of a campaign to address childhood stunting.
This mini Report was commissioned to The Consultant by The World Bank as part of its support to the
Government in Indonesia to develop a situation analysis and overview of past campaigns, an appropriate
communications strategy and a final terms of reference (TOR) for contract bidding. This report only contains
information and findings related to the result of stakeholders’ consultation (pre-socialization meetings) that
was conducted in Jakarta, Indonesia, from November 2012 until February 2013. A more comprehensive
version of the report can be reviewed in the Public Health Communications Campaign In Indonesia: Lessons
Learned and The Way Forward document.
Key methods in conducting the assessment were:
a. A comprehensive desk review of the existing draft of the public health communications campaign
situation analysis.
b. An extensive in-depth interviews and meetings with key stakeholders from the Ministry of Health
(Head of Nutrition, Head of Health Promotion, Head of Healthy Settlement and Public Places, and
senior staffs), National Planning Board (Bappenas, Director of Poverty Reduction), UNICEF (Head
of Nutrition, Head of Communication for Development and staffs) and representatives from the
Millennium Compact Indonesia (MCI). List of interviewees / key stakeholders included in Annex
A).
The Consultant used the existing draft of the campaign situation analysis as a tool to socialize report
recommendations with key stakeholders in three power point formats (attached).
4. THE FINDINGS
Consultation meetings with a total of twenty one key stakeholders of MCI and Technical Working Group from
the Ministry of Health (Head of Nutrition, Head of Health Promotion, Head of Healthy Settlement and Public
Places and staff), Bappenas and UNICEF were scheduled between November 2012 – February 2013 in Jakarta.
The list of the stakeholders (interviewees) and their contact details can be reviewed in Annex A. The objective
of this meeting was to discuss the situation analysis for the National Stunting Awareness Campaign draft and
as part of assuring the final ToR and Communication Situation Analysis to include feedback from all of the key
partners involved in the MCC Community Based Health and Nutrition to Reduce Stunting Project in Indonesia.
The situation analysis document reviews roughly 30 past health communication projects in Indonesia and
Timor Leste from 1988 – present, four case studies including family planning, PD Hearth, Suami Siaga and
vitamin A, by governments as well as local and international agencies to capture the broadest possible scope
of initiatives and lessons learned. Annex B, C and D in power point formats were used as the communication
tool that was shared and presented during the interviews.
The following are the findings from the in-depth interviews:
A. LESSONS LEARNED – BEST PRACTICES FROM PAST CAMPAIGNS When asked about the highlights from the past campaigns and examples of best practices from past campaigns
that could be learned, majority of the informants mentioned The Blue Circle (Lingkaran Biru) campaign
(Indonesian Family Planning Program) as the most successful campaign of all time and the first thing that they
remembered on top of their mind.
This Blue Circle campaign supported by the Indonesian National Family Planning Coordinating Board (BKKBN)
was established in 1970 and over the next 25 years developed a strong family planning infrastructure at all
levels of government. As one of the officials from the Ministry of Health stated:
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“The Blue Circle (Lingkaran Biru) is one of the most successful campaign ever, perhaps we could learn to
replicate its strategy in mobilizing all people from the military to the village leaders…”
The following are additional campaigns that were considered to be the best practices in communication
campaign from the in-depth interviews with the stakeholders:
Desa Siaga (Reducing maternal and infant mortality)
Education Campaign (Wajar: Wajib Belajar 9 Tahun)
Measles
Polio
Avian Influenza School Program
Accelerating universal salt iodization
Global Handwashing Day Campaign
Healthy four, perfect five (Empat sehat, lima sempurna)
One of the informant from the Ministry of Health shared his thoughts regarding the successful slogan of the
Healthy Four Perfect Five campaign, however, he believed that there is a need to revise the overall
understanding of the slogan’s content.
“Healthy four, perfect five (empat sehat lima sempurna) has been a successful slogan, but we need to fix the
content of this slogan.”
Other best practices that were mentioned was the lessons through using action posters from the 1980s with
the Manoff Group, Marcia Griffith.
“There was an interesting experience back in the 80s with The Manoff Group that worked out well through
action posters, however, when we scaled it up, we had to deal with many challenges and ended up simply by
distributing posters, there was no evaluation, thus we had no clue on our strengths and weaknesses…. The term
‘bubur campur’ or bubur saring’ worked out very well though… perhaps we could learn from its success…”
From the consultation, it was clarified that the lack of comprehensive monitoring and evaluation in past
campaigns has been a major problem that needs to be solved.
B. Key Players for the Ad-Hoc Team and Suggested Time Frame
Informants representing the Ministry of Health specifically from the Health Promotion and Nutrition
Departments clarified their recommendations regarding the key players that need to be involved in the ad-hoc
team for the organization structure that should provide direction and deliver prompt responses in terms of
decision making in relation to the grand design communication campaign, including representatives from:
The Ministry of Health and The Medicine and Food Monitoring Center (BPOM)
Ministry of Internal Affairs
Ministry of Communication and Informatics (Kemkominfo)
Ministry of Agriculture (Kemtan)
National Planning Board (Bappenas) As stated by one of the officials from the Nutrition Department from the Ministry of Health:
“The key players for the ad hoc team should be divided by its specific roles and expertise, stunting issues should
be represented by the Ministry of Health (Kemenkes) and Medicine and Food Monitoring Center (BPOM =
Badan Pengawas Obat dan Makanan), the Ministry of Internal Affairs (Kemendagri) are the ones that would
have significant role in conducting advocacy to all levels, Ministry of Communication and Informatics
(KemKominfo) is in charge in disseminating information, Ministry of Agriculture (Kementerian Pertanian) plays
a significant role in food and poverty reduction, last but not least would be Bappenas that coordinate
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everything, perhaps we could also include private sectors such as GAKMI: Gabungan Asosiasi Makanan dan
Minuman, it’s open for discussion…”
The proposed organization structure, suggested time frame, and campaign steps that were presented by the
Consultant during the discussion received an approval and support from all of the informants. (See Figure 1
and Table 1 below).
Figure 1. Proposed Organization Structure to support the Health Communication Campaign Strategy
Contractors are companies that are selected through a competitive selection process that requires
specific expertise in the implementation of the campaign.
The campaign management team is the team that is responsible for the
day to day management of the campaign and oversee contractor’s
performance
The ad-hoc team is the cross-sectoral team that is responsble to
lead and provide the direction of the campaign and provide final decision
making
SUN Structure
Ad-Hoc Team
Campaign Management
Team
Contractor
Formative Research
Contractor
Advertising Agency
Other Contractors
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Table 1. Proposed Project Phases and Time Frame
Majority of the informants repetitively mentioned the importance of understanding all of the different target
audiences for this campaign, from policy makers to village leaders and others, a socio ecological model
approach is highly recommended to be implemented. There is a need to be sensitive to the target audience’s
level of education to achieve significant sustainable impact from this campaign. A simple key message (simple
approach) that is repetitively broadcasted or heard in high frequency is more favored than a complicated
unclear long messages.
An informant from the Health Promotion Ministry of Health encouraged the initiative to learn from private
sector’s communication strategy, specifically the tobacco company that has succeed in creating engaging and
powerful taglines that remain on top of the mind of majority people. It is noted that the popularity of the
tagline does not guarantee the expected behavior change from the communities.
C. Theme
“There is no use to have themes changing every year with no clear direction on what to achieve at the
end.”
The quote above was stated by one of the high officials from the Ministry of Health. Clearly, similar mistakes
and approaches have repetitively occurred for years, including not having a clear direction on what to achieve
through the yearly ever-changing themes of a campaign.
Project Phases Time Frame Steps in Communication for Behavior Change
Preliminary Assessment
Pre-Campaign: 2012
Q4 Carry out communication situation analysis
Q4 Obtain inputs and share the result with relevant stakeholders
Identification Phase I: 2013 (Y1)
Q1 Formation of ad-hoc team that includes relevant stakeholders
Q1 Determine and gain consensus on broad communication for behavior change objectives based on overall project goals
Preparation Q1 Review existing information and analyze information gaps
Q1 Complete assessment of institutional capabilities and decide on basic responsibilities, including hiring of technical consultants
Q1-Q3 Plan and conduct initial formative research
Appraisal Q4 Review of formative research result
Q4 Design a general campaign guidelines
Contracting Q4 Selection process for advertising agency and other companies if needed
Development Q4 Develop behavior change strategy, including its communication component but also link to training needs, product, etc, including pre-testing the materials
Q4 Stakeholder meetings to inform and gain consensus on the behavior change strategy
Implementation Phase II: Year 2014-2016 (Y2 – Y4)
Y2 Q1 Assign responsibilities for materials preparation, training and remaining research, including monitoring and evaluation
Y2 Q1 Produce the communication for behavior change materials
Y2 Q1 Prepare to implement communication and other components of the behavior change strategy including training
Y2 Q1 Plan, conduct, and analyze a baseline survey
Y2 Q2 Launch campaign
Y2 – Y4 Implement communication activities
Y2 – Y4 Monitor and adjust project activities
Evaluation Phase III: End of 2016 (Y4)
Y4 Q4 Plan and conduct an impact evaluation
Completion After 2016 (Y4 – beyond)
Y5 Disseminate project achievements and lesson learned
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One of the representatives from the Health Promotion Unit expressed his idea to take advantage of this
momentum to get the message ‘right’ and at the same time connect to the SUN (Scale Up Nutrition) National
program in Indonesia, ‘fix’ the healthy four perfect five successful slogan and build the awareness with the
right content. Moreover, all of the informants agreed that the word/theme ‘stunting’ might be something that
is too complicated to be ‘promoted’.
“I completely disagree in the use of the word ‘stunting’ for this campaign, it is not a word that can be easily
understood by mothers, perhaps we could use the word ‘malnutrition’ and link it to child rights.”
From the consultation, it was highly suggested to have one main theme, supported by several sub-themes for
a particular range of time, the decision regarding specific themes and sub-themes will be supported by the
data and evidences taken from the formative research.
D. Formative Research
Research plays the key role throughout this process such as in understanding the issue and audience to
develop an effective strategy, in tracking the implementation of the program and in assessing the success of
the efforts. Formative research specifically, aids in the development of the strategy and includes the problem
and environmental analysis, target audience research, and pretesting of messages and materials. The role of
formative research is to guide the initial development of the program and will help answer questions in
relation to the problem (stunting), the context in which the problem exists, the target audience, the target
audience’s behavior, perceptions as related to the problem, the main barriers keeping the target audience
from taking action, the best and most effective way (communication channels) to reach the target audience,
which messages and materials that will work best, etc.
Formative research is highly approved and recommended to be implemented prior to the implementation of
the campaign. As a high official from The Ministry of Health stated:
“Formative research is crucially needed before conducting the overall health communication campaign. We
need to figure out the clue and have an evidence based documentation on the perceptions, attitude and
practice of mothers in relation to their children’s growth, what is important for them? Their brilliance? Their
physical appearance (beautiful handsome?), their height? Their weight?. I totally support the need of having a
formative research before conducting the campaign.”
Another informant representing the Health Promotion Unit from The Ministry of Health added:
“It is important for us to know the relation between stunting and smartness/brilliance. We do not want people
to see that this stunting issue is something that we make up/create. “
E. Grand Design: National Communication Campaign Strategy
From the in-depth interviews, several informants were convinced regarding the need for the Government of
Indonesia to produce a grand design of the communication strategy that eventually would encourage private
sector to contribute and play a role in it. A grand design of the health communication strategy will be endorsed
by the MoH to support the campaign to reduce stunting.
“It is time for the Ministry of Health/Government of Indonesia to have an official 5 year grand design strategy
of communication campaign, fully endorsed, with proper formative research and monitoring evaluation. This
time a monitoring evaluation stage within the strategy must be included!”
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A High Level informant from the Nutrition Unit Ministry of Health expressed his dream to allocate and make
the best out of the IDR 30 Billion budget in supporting his programme through a potential collaboration with a
particular TV show that is a huge success/ high rating based on Nielsen Media Research (i.e. Tukang Bubur
Naik Haji – RCTI TV prime time evening episode), this would be an option for one of the many communication
channels that could be considered to support the implementation of the strategy.
“My dream is to take advantage of the mass media, collaborate with private sector and high rating soap
operas (Tukang Bubur Naik Haji) and insert the ‘taburia’ and/or ‘exclusive breastfeeding’ behavioural change
messages within several episodes that are broadcasted and viewed by millions of viewers. I am willing to
commit the budget for that as long as its allocated at the right timing and within an ideal frequency.”
E. Key Problems Identified
Based on the findings previously mentioned, there are several key problems that were identified:
1. The absence of a national grand design communication campaign strategy (lack of clear direction)
2. The need to improve integration and coordination including setting clear roles and responsibilities
3. Lack of coordination
4. Lack of support (action) from the High Levels of Government Officials
5. Complicated cultural and political situations in difference provinces and districts
6. Cash disbursement approach VS behavior change expectations approach in the overall implementation of
the communication campaign strategy.
5. Recommendations
Based on all of the findings and key problems previously mentioned from the stakeholders consultation, the
following is the list of recommendations to move forward:
1. A technical working group (ad hoc team) should be established.
Since lack of coordination is one of the major challenges identified, it is recommended that the ad hoc team
should be established fairly soon. Building support for campaign’s goals at all levels is critical to its success. All
roles, rights and responsibilities should be clarified in advance.The ministries/key players (Ministry of Health,
Ministry of Communications and Informatics, Ministry of Agriculture, Ministry of Internal Affairs, Bappenas,
etc) should provide all necessary support within their capacities. The establishment of a working group – ad
hoc team is essential to enforce common understanding and objectives, facilitate information sharing as well
as identify and explore opportunities to integrate . The working group will also be responsible in reviewing
strategies to ensure their quality. An open minded approach from all ministries welcoming other sectors to
work together is highly suggested.
2. As a short term solution, the members of the Ad Hoc team should collectively review and conduct a meeting
regarding the implementation of previous communication campaign within their ministries and set short term
objectives. It is a good idea to conduct the review meeting/workshop in detail regarding the consequence and
lessons learned, this workshop should aim at building a common understanding on the main objective and
approach as well as managing expectations between all ministries. It will also be a chance to build rapport
between all ministries which usually have limited interaction.
3. Conduct Formative Research prior to the implementation.
Careful formative research anchors successful campaigns. The strategy should be conducted using the
appropriate methodology which includes proper behavioural surveys and plans for monitoring and evaluation.
State clear roles and responsibilities of each section as well as set the ground rules for cooperation and
integration. Based on the past experience and lessons learned, monitoring and evaluation is highly essential
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to be included in the overall strategy and process. The themes and sub-themes will emerge from the result of
the formative research, awareness should be built on one issue, a clear key messages and what behavior that
is expected to be changed should be decided and agreed in advance. Consistency of the campaign messages
and design should be ensured. Stunting prioritization of issues can range from complementary feeding, micro
nutrient products, exclusive breastfeeding, handwashing with soap, etc. The programme should be linked to
the Government’s national programme such as SUN (Scale Up Nutrition), PHBS (Perilaku Hidup Bersih Sehat)
and UKS (Usaha Kesehatan Sekolah).
4. Produce a grand design communication campaign strategy, endorsed by the MoH/GoI.
Socio Ecological Model as a framework and concept for the grand design strategy is suggested during the
consultation. This will be the first grand design that MoH will endorse for the very first time. It is highly
recommended to also apply some of the the Blue Circle and Desa Siaga’s lessons learned in involving all sectors
and all levels to support the programme. Apply a 360 degrees and multi level contractors approach, strong
advertising and formative research agencies, synergy is the key. Capacity building and providing technical
support for the health promotion unit team in the Ministry of Health is highly suggested.
Conclusion
The stakeholders consultation confirms that the Government of Indonesia, Ministry of Health specifically, has
done a lot of health communication campaigns for years. The challenges include the various levels of interest,
objectives that have not met expectations, understanding and capacity within each ministries, the absence of
the national grand design communication campaign strategy, lack of coordination between national,
provincial, district and ministries and many others. These challenges can be overcome if each ministries is
committed to share information and implement integrated program using the agreed model/strategy.
Improvements should be executed as soon as possible, immediate steps to review past practices and set short
and long term objectives must be implemented to maximize results.
As stated in the early section, a more comprehensive and detailed situation analysis of this as well as the road
map for building a campaign strategy and the outline process for contracting with anticipated firms can
reviewed in another document titled, Public Health Communications Campaign: Lessons Learned and The Way
Forward. The recommendations and conclusions in this document will be added to the more comprehensive
version. The conclusions reached in these assessments will inform the development of an approach to a multi-
year national awareness campaign on stunting. A contracting frame work for the campaign will be produced
along with a Request for Proposals (RFP) including Terms of Reference that will aid the process of sub-
contracting the development and implementation of aspects of this campaign to the private sector in
Indonesia. The ToRs will be produced once the current drafts have been reviewed and strategic decisions
made about the scope and scale of the campaign.
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ANNEX A : LIST OF KEY STAKEHOLDERS
Organization Name/ Contact Person
Contact Details Meeting Schedule
MCI Jl. Subang No. 10 Menteng Jakarta Pusat
Iing Mursalin Nura Dirgantara Lila Anas Syahrial Loetan
[email protected] [email protected] [email protected]
20th November 2012 14.00 – 16.30 28th November 2012 10.00 – 13.00
BAPPENAS Jl. Taman Suropati 2 Jakarta Pusat 10310
Rudy Prawiradinata Nina Sardjunani Hadiat
[email protected] [email protected] [email protected] [email protected] Marli – 0812 1338 3560
20th December 2012 11.00 – 13.00 April 2013
MINISTRY OF HEALTH Subdirectorate Healthy Settlement and Public Places Jl. Percetakan Negara 29, Jakarta Pusat Jl. HR Rasuna Said Blok X5 Kav 4 – 9, 7th floor Jakarta 12950
Handwashing Wilfried Purba Nutrition Minarto Entos Nasir Dian Health Promotion Lily S. Sulistyowati Bayu Hana (Kabid Metode dan Teknologi) Bambang (Kabag TU) Rarit (PP Peran Serta) Nana (Advokasi dan kemitraan) Maulina
[email protected] [email protected] [email protected] Ayu - 0813 11 520 127 [email protected] [email protected] [email protected] Venti - 0856 110 1078 Bella - 0812 90 66671 [email protected] [email protected] Bayu – 08129192627 Riri – 08 111 39 295
10th December 2012 10.00 – 13.00 9th January 2013 14.00 – 16.30 16th January 2013 14.00 – 16.30
PSF Jl. P. Diponegoro Menteng Jakarta Pusat
Rob Wrobel Sadwanto Gerda
[email protected] 19th February 2013
UNICEF Wisma Metropolitan II, 10th Floor Jl. Jend. Sudirman 31 Jakarta Selatan
Sonia Blaney Supriya Mukherji Iwan Hasan
[email protected] [email protected] [email protected]
30th November 2012 14.0 – 16.30
Other Interviews Conducted: UNICEF (Nutrition, Communications For Development), GAIN, Australia Indonesia Partnership for Maternal and Neonatal Health, The Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHIPEGO Jakarta), World Food Programme , Helen Keller International , Savica Communications, Save the Children, London School of Hygiene and Tropical Medicine, The World Bank Water and Sanitation Program, PNPM Generasi Project Support Facility, Center for Evaluation Research at Johns Hopkins Bloomberg School of Public Health, Three account managers from Jakarta PR firms (requested anonymity)
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DOCUMENT 2 – CAMPAIGN STEPS
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DOCUMENT 3 – FEEDBACK
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DOCUMENT 4 - COMMUNICATION CAMPAIGN PLAN
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