COLUMN ONE : Popular Population Control : Indonesia’s family planning program has become a model for the world. A mix of moderation, Madison Avenue and Islamic teachings has overcome staggering odds.
In the 1960s, demographers warned Asia’s crowded nations that unchecked population growth was a threat to their survival. China and India resorted to such brutal tactics as forced sterilization and compulsory birth control.
In Indonesia, however, moderation has been the key to a great success in population planning. The government has soft-pedaled contraception and promoted a “small, happy and prosperous family,” using a mix of Madison Avenue hoopla and Islamic teaching.
This strategy has overcome staggering obstacles in Asia’s third-most-populous nation, where more than 110 million people are shoehorned onto just one of its main islands, Java, which is the size of Wisconsin.
More than 70% of its residents were illiterate and earned less than $50 a year. Muslim clerics raged in their pulpits against birth control. Rural people favored huge families as a way of working the farm.
But Indonesia’s success has been just as significant. Between 1970 and 1991, fertility declined from an average of 5.6 to 3.0 births per woman; the government hopes that by 2005 the birthrate will drop to 2.1, the “replacement level” at which the population, statistically, ceases to grow.
By 1990, Indonesia’s population was 179.3 million instead of the projected 191.7 million it would have been without family planning. The difference, 12 million people, is nearly 3 1/2 times the population of the city of Los Angeles.
“Most people regard Indonesia as one of the great success stories, reducing fertility by 45% and increasing the use of contraceptives from 10% (of the population) to 49% in only 20 years,” said Kenneth R. Farr, a population expert with the U.S. Agency for International Development. “To change demographics like this in only 20 years is a really significant accomplishment.”
The Indonesian program has also proved a rare instance of untarnished achievement for U.S. foreign aid, which has provided more than $250 million since the early 1970s. Although the level of U.S. aid has dropped in recent years, the results have kept improving, a sign that the program can stand on its own legs.
So successful is Indonesia’s population control effort that experts from 67 countries, including even developed countries such as the United States and Britain, have come here to study family planning and to try to borrow some of the more transportable ideas.
An example of the program’s soft approach can be seen in the experiences of Supriti. She is the 22-year-old wife of a Jogjakarta businessman who had her third child only a month ago. A few days after the birth, a volunteer appeared at her door to talk about family planning as part of the gotong royong , or mutual self-help program.
“I didn’t want to have any more children,” said Supriti, who in the Javanese tradition uses only one name. “We’re still living with my parents, and we cannot afford to have more.”
The volunteer organized government transportation and brought Supriti and five other women from their village to Wirosaban Hospital in this provincial capital.
Previously, Supriti had been using an injectable contraceptive but became pregnant when she stopped for a few months. Now, in less than an hour, she emerged with a bandage over her upper left arm where she had received Norplant--a U.S.-developed implantable contraceptive that lasts five years--at no cost.
“It didn’t hurt at all,” Supriti said. “I am still young. I don’t need any more kids.”
Thanks to its consensus-style approach, the family planning program has already achieved its goals in five major provinces--Jakarta, Jogjakarta, Bali, East Java and North Sulawesi--where population growth is below the 2.1 birthrate. But with its population spread over 13,000 islands, Indonesia faces a daunting task improving on this effort’s success.
The program has been criticized for not staying in step with the times. Indonesian and Western experts believe that Indonesia’s family planning effort is entering a critical new phase as the number of women practicing birth control appears to be reaching a plateau and the government appears to be ignoring such concerns as premarital sex and AIDS because of political considerations.
But Indonesian authorities maintain that achieving “replacement level” population growth is the program’s main target. They are confident it remains a viable goal.
Much of the credit for Indonesia’s success belongs to Haryono Suyono, the ebullient chairman of the government’s National Family Planning Coordinating Board, who in March was elevated to the Cabinet as state minister of population.
A 55-year-old bundle of energy and a nonstop talker, Suyono holds a doctorate in sociology from the University of Chicago, where he specialized in communications. He is fond of saying that he peddles family planning the way Americans sell soap or other consumer products.
Although the program is well entrenched--a recent survey showed that 94% of married women were familiar with birth control--it was a fairly risky step when President Suharto launched the campaign in the 1960s. Nationalists, such as his predecessor, President Sukarno, had condemned birth control; the Muslim clergy in this overwhelmingly Islamic nation was overtly hostile. But Suharto’s unflagging support for family planning is often cited as the key to the program’s success.
Suyono acknowledged that the program’s early years were spent searching for a way around Muslim opposition. In the end, authorities adopted a top-down approach, making officials all the way down to village chief responsible for making the program work. Village ulemas , or clergy, were also drawn into the program as “front-line coordinators.”
“In the first 10 years, we were really getting pressure from donor agencies, asking why we didn’t recruit more ‘acceptors’ (of the birth control program) instead of spending so much time talking and talking,” Suyono recalled in an interview. “But we considered this the best way, making friends and explaining that we are not doing anything harmful to the community.”
The obstacles to the program’s success were monumental. Almost 70% of Indonesia’s population was illiterate at the time, so traditional information campaigns were useless. Suyono initiated a public relations onslaught by word of mouth, using such devices as puppet shows to get out the message of a “small, happy, prosperous family.”
It was a subtle kind of parallel advertising, the way tobacco companies show virile cowboys rather than ordinary people smoking cigarettes. Rather than pushing condoms and birth control pills, the program’s promoters cited the Koran on the need to strengthen the family. Only years later did the government begin overtly urging people to use contraception.
“Islamically, there is nothing wrong with family planning,” said I. A. Suparman, a Muslim scholar at Jakarta’s Center for Institutional Development Research. “People can now see that having less children means more benefit to them. They had to overcome this feeling that to have more children is better.”
Because of the controversy over China’s harsh birth control program, Western aid agencies have tried to keep Indonesia from coercing people to join its program. Pressure to join was strongest at the local level, where government officials themselves were under scrutiny from above to produce results and meet national targets.
Another controversial aspect of the program was the “safari,” in which doctors descended on remote villages, gathered local women and en masse fitted them with inter-uterine devices (IUDs), a procedure many found coercive. Suyono said both the safaris and the annual targets have been phased out this year because of criticism.
There are a few positive inducements to keep people in the program, from offering valuable agricultural products to those who participate for five years to scholarships and even free trips to Mecca during the hajj, or annual Muslim pilgrimage. Civil servants receive a subsidy for restricting themselves to three children.
In the late 1980s, surveys showed that a sizable segment of Indonesians resisted birth control because it was provided by the government, which they didn’t trust, and was free, which made them suspicious.
So the government began encouraging private doctors and midwives--who charge fees for their services--to make contraception available, a program known as mandiri , or self-reliance. By last year, 22% of 21 million people practicing contraception were paying for the services at private clinics, a figure Suyono hopes will rise to 40% or 50% by the year 2000.
The entire program costs $200 million a year, of which 15% comes from international donor agencies. That is down from 75% support 20 years ago, Suyono said. The program has 48,000 full-time employees.
Despite its success, Indonesia must add 10 million more birth control users to achieve its goal of a 2.1 birthrate by 2005. An estimate by a U.S. aid agency suggests that this means the number of couples practicing birth control must increase from 49% of those of childbearing age to nearly 63%.
One way the government is attacking the problem is to encourage women to have children later. In the last 10 years, women’s average marriage age has risen from 18 to 22. Women are also encouraged to work and stay in school; next year, the mandatory minimum education will increase from six to nine years--with an unintended benefit in delayed child rearing.
Suyono, ever the salesman, has devised a program to encourage young couples to take a “honey-year,” instead of a honeymoon, delaying their first child for months, if not years. The idea is to target women in their early childbearing years rather than older women who have several children and have to be discouraged from having more.
Another government program is sending 11,000 trained midwives to the villages each year so that in three years every village will have a person with medical training. The midwife program is designed to reduce Indonesia’s horrendous death rate for mothers during delivery, currently 100 times higher than in the West; the health professionals also will provide family planning information.
Indonesia does not rely on a single birth control technique or method--unlike China, for example, which primarily uses sterilization. Pills are the most popular, then injectable contraceptives, followed by IUDs, implants, condoms and sterilization.
IUDs are the most controversial because in conservative Muslim areas husbands refuse to allow doctors, who are usually male, to insert them. Condoms, used by only 3% of program participants, have never been popular for family planning in conservative Indonesia because they are associated with prostitution.
A controversial element of the program is that it is designed exclusively for married couples. While single people can obtain contraception from private clinics, the government is being careful not to “contaminate” its successful family planning effort by discussing safe sex and AIDS prevention--topics considered taboo because they imply sex outside marriage.
Kartono Mohamad, chairman of Indonesia’s Planned Parenthood Assn., said the country is facing the possibility of a baby boom because there are 50 million people in the sexually active ages of 14 to 24. “The government doesn’t have the courage to touch that area for political reasons,” Mohamad said.
When asked about this, Suyono said: “Oh, boy. We had a lot of negative reaction with only married couples 20 years ago. Why should we create a possible enemy?”
Similarly, the government program avoids all discussion of abortion, even in cases where women with large families unintentionally become pregnant while practicing some form of birth control. “We never discuss it,” Suyono said.
Abortion is illegal in Indonesia, but a 1992 revision of the Family Health Act permits doctors to use unspecified “certain measures” to save the life of a pregnant woman. One 1990 study estimated that there are 750,000 to 1 million abortions each year.
Firman Lubis, executive director of the Kusuma Buana Foundation, a private group involved in family planning research, believes that the government program may be endangered by its own success. With incomes rising and the population declining, many middle-class couples are arguing that they can afford to have more than three children.
“Frankly speaking, I doubt if the government can achieve its goals,” Lubis said of the 2.1 birthrate targeted by 2005. “They are now reaching (the) harder core. Unwanted pregnancies are still quite high, but they are reluctant to touch issues like abortion. Like many big businesses, the government’s program is too slow to adjust.”