Community empowerment as a way of improving public health in vulnerable and growing urban areas in developing countries; Empirical results from Indonesia

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Community empowerment as a way of improving public health in

vulnerable and growing urban areas in developing countries;

Empirical results from Indonesia

Hanna van Loosen (S2416506)

Supervisor: Dr. Pennink

Co-assessor: Dr. J. Shin

University of Groningen

Faculty of economics and business

Master International Business and Management (IB&M)

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_{of March 2019}

Wordcount: 10374

Lange veemarktstraat 5, 8601 ET Sneek

+31683607535

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Preface

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Abstract

The concern for the health of people living in urban areas in developing countries, is increasing. Rapidly growing urbanization rates in combination with serious challenges with regard to a country’s public health, is causing a threat. An approach to this threat is desirable and community empowerment might be an interesting concept to explore in this context. The focus of this research will be on Indonesia, where it will be carried out at an NGO and among inhabitants of Jakarta. The research exists out of a case study and 6 open interviews, which were the input for another 5 semi-structured interviews. Analysing the data resulted into two main results: (1) 4 factors which influence community empowerment in both a rural and urban context and (2) 4 differences between the both, which affect community empowerment in cities. These two main results are highlighted in a conceptual model and give a broad idea of how community empowerment could improve public health in Indonesian cities. The results can be used for further research and are an early attempt to describe how community empowerment could be used in programs to improve public health in cities in Indonesia.

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1. Introduction

The awareness about public health in urban areas is increasing as the population of cities is expanding at an incredible rate (Shanahan et al., 2015). Public health in cities is mostly negatively affected by diseases, impoverished health and sanitation facilities, inadequate housing, environmental challenges and poverty of the inhabitants (Günther & Harttgen, 2012; Zulawski, 2016; Gries & Grundmann, 2018). This is especially the case in cities of developing countries, which are crowded and poor, where the urbanization rates are also high and keep increasing rapidly. The United Nations expects urbanization rates in developing countries to grow rapidly and reach 84% in 2030 (United Nations). This means that the affected population will keep increasing and an approach to deal with this threat is necessary. It is for a reason that one of the sustainable development goals of the UN is ‘ensure healthy lives and promote well-being for all at all ages’ (UN sustainable development goals, 2018). Besides that, good health and well-being is a human right and therefore something we must try to achieve globally (UN, 2018). Not only is it important just for the sake of a country’s public health, it is also important for a country’s development; healthy people are more productive and are important in order to build a prosperous society (Novignon et al., 2015). However, the dynamism of a city can be a difficult challenge and requires a different approach compared to working in a rural context (Humanitarian Exchange, 2018).

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village (Macfarlane et al, 2000; Ahmad & Abu Talib, 2012; Thunhurst, 2013; Schuringa & Sibande, 2014; Conyers & Cumanzala, 2014).

Given the fact that urbanization is expected to increase rapidly within developing countries, these areas are vulnerable to humanitarian crises regarding its public health and the managing process for these settings are challenging and unclear, this is an important topic to explore. Previous facts and information results in the following research question:

How does community empowerment improves public health in cities in developing countries?

However, an important part of Thunhurst’s research showed that every country is different and that designing one policy for all, is almost impossible. Islam (2017) also states that every case should be handled differently; it is impossible to develop a community empowerment framework which can be used globally simply because every village, city and country is unique. That is the reason why for this research there will be a focus on one developing country, namely Indonesia. Indonesia has many cities of which most have serious issues with regard to their public health (Hartiningsih & Widiadana, 2014). Jakarta is an excellent place to conduct this research, since it is a very large city with a lot of inequalities and diversity. This leads to the following addition to the research question:

Research in an Indonesian context.

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community empowerment and it could be very useful for public health in Indonesia and other developing countries.

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2. Literature on public health and community empowerment

There are two important concepts in the above stated research question, namely community empowerment and public health. Since this research is focused on these two concepts, they will be highlighted in the following paragraphs.

2.1 Public Health

2.1.1 Definition of public health

In order to decrease urban vulnerability and create a prosperous country, public health in general needs to be improved. Public health can be defined as “the science of protecting the safety and improving the health of communities through education, policy making and research for disease and injury prevention” (University of Pittsburgh). Another frequently used definition is that of Dean Acheson who explained public health as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” in 1988 (WHO, 2012). Public health is a broad concept and encompasses the overall health of a particular group, community and/or society. The focus of public health is not only on factors that influence the health of a group but is also concerned with the health of individuals (Ashton, 1990; Jensen et al., 2018). So, public health is something that can be achieved and perceived as a group but also on an individual level. However, the aim of this research is to explore what community empowerment could do to improve public health, therefore this research will mainly focus on improving public health on a group level.

2.1.2 Importance of public health

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being at micro level. Therefore, programs should be effective and focused on improving population health (Novignon, 2015).

2.1.3 How to improve public health

Improving public health can be done in so many different ways depending on the specific goals and actions. The World Health Organization (WHO) gives several essential public health operations, like checking the population’s health and well-being, promoting health by actions to address social determinants or preventing disease and the early detection of illness. A more practical example of improving overall public health could be setting up interventions such as programs to reduce alcohol intake or the amount of people who smoke (The Marmot Review; RIVM, 2018). Programs like these must be designed in order to bring a significant benefit for a substantial group of people, even though this might mean that there are minor infringements of an individual’s freedom. It is important to find a balance between freedom and community benefits (Krebs, 2008). These programs could be organized top down by the government, who will implement a certain policy or program, or bottom up like empowering communities themselves. This is something what Thunhurst (2013) concludes from his research when he stated that at the regional (meso) and local (micro) level, it is essential to achieve the involvement of the community and its representatives. Therefore, a concept like community empowerment might be useful, since public health will be improved as a community.

2.1.4 Public health in Indonesia

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diseases, dealing with unhealthy diets and improve preparedness to disasters urban areas could be approached by educating communities and empowering them. By empowering communities within urban areas and provide their community leaders with necessary education and resources regarding these issues, they will be able to achieve success through their community’s social capital.

2.1.5 Public health through Social Capital

The above stated five issues give a broad idea of the main issues in Indonesia’s public health. Even though those illnesses strike an individual, public health is something that could be approached by the support of the community’s social capital. Social capital is quite a complex concept but it encompasses links, shared values, sympathy, connections and social intercourse among individuals resulting in a social unit, a community, which enables them to trust one another and work together (OECD; Putnam, 2000; Baylis et al., 2018). Social capital can be developed through collective networks and resources, which are formed in a community between people. It has a potential to create positive health and lead to social outcomes for communities who are less developed and have problems (Arthurson et al., 2014). Arthurson et al. explain in their article how social capital is also something that governments could invest in. Numerous academic findings show that the quality of social relationships between people in a community can be associated with economic growth and quality of health and education. Their own research showed how the two groups they interviewed, policy makers and practitioners, saw social capital as “reflecting the social connections and networks within a community along with prospects for these aspects to promote health and well-being” (p. 84). Instead of the government directing laws and policies top-down in order to improve public health, the social capital of communities should be used to achieve improvement. By using community empowerment, a community’s social capital can support the improvement in public health.

2.1.6 Recap of public health and its importance for the research question

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locals, a different outcome can be achieved compared to when the government controls and decides everything. Using a community’s social capital can have an enhancing effect on improving public health as a community through connections, social intercourse and trust. Indonesia’s public health issues could be dealt with based on the needs of a community, creating commitment and using social capital.

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2.2 Community Empowerment

2.2.1 Definition of community empowerment

In order to explain the concept community empowerment, it will be split up in two parts. A community is a social group, which has one or more things in common and also identifies themselve as a community. Whereas empowerment can be defined as “the power to accomplish something individually or collectively” and it is something that especially enables the poor to overcome barriers and improve welfare (Saegaert, 2006). Ahmad and Abu Talib (2016) explain community empowerment as a way to realize improvement through community participation and building capacity as a community. This community creates a “sense that one belongs in and is meaningfully part of a larger collectively” (Sarason, 1986), which results in behaving in such a way that it contributes to the respective social structure (Ahmad & Abu Talib, 2016). Community empowerment is an approach that establishes mechanisms to mobilise community resources and this leads to solving problems as a community (Schuringa & Sibande, 2014). Especially in developing countries where people are poor, community empowerment is a way to realize desired improvement. Schuringa and Sibande (2014) explain how those poor communities can be characterised by a culture that is based on being marginalised, which results in passive, apathic, indifferent and individualistic behaviour. This kind of behaviour in combination with problems of daily life and lack of future perspective cause failure of improvement on different aspects of life, of which public health is one. Since community empowerment focusses on getting people involved and realizing local solutions as a group, this is an approach which will most likely change attitudes and create motivation to achieve goals among the members who are involved.

2.2.2 What is a community

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community empowerment takes place in a rural or urban area, it is important to assess the context and implement programs in a community which is perceived as a community by the members themselves.

2.2.3 Examples of community empowerment

How this concept of community empowerment can take shape will be explained by giving two examples. Macfarlane et al. (2000) give an example in their article about an area in Kenya, where about 5000 families live, which has high criminal rates. In order to improve this area, a pan-Africa network called the African Network for the Protection and Prevention of Child Abuse and Neglect implemented an approach to organize communities in a new way. They started with training locals, so that they would be able to develop empowered communities. This resulted in communities electing their own leadership and prioritising needs of the community. Because of the empowerment, locals got confidence and motivation to deal with all kinds of issues their community was struggling with. Where this program started with the goal to improve criminality rates by training local organizers, it resulted in all kinds of achievements like cleaning the area of garbage, secure water drainage, target diseases and even a cooperation between community leaders and the government.

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demonstrated that there is a possibility for ordinary members of a community, with the help of suitable education and position within the community, to grow into a respected member who can influence and lead other members. One of the projects, even though it only started two years ago, resulted in building a dam, a fish market, a primary school and water and solar power supply. What made these big achievements possible in such a relative short amount of time, was the fact that the communities saw it as their own projects. The main idea behind this whole event, was an external party who educated and empowered prominent members through an existing structure within one community. This allowed a local community to achieve their ‘own’ goals with the knowledge and help from an external party.

2.2.4 The fundamentals of community empowerment

The examples given in the previous paragraph show that there is not one form of community empowerment and how it should be carried out, but there are some important fundamentals of this concept. The examples show that locals got increased power and instead of top-down the approach shifted to bottom-up. A positive thing about this, is that the community will get to control the situation and this internal process has a higher chance to realize success compared to scientifically designed interventions (Macfarlane et al., 2000). Besides that, the communities where the programs were implemented, were close communities and members felt connected. Since community empowerment is considered as a key to change attitudes, individually and as a common effort (Ahmed & Abu Talib, 2016), it creates a feeling of unity where local taken decisions are supported by members of the community. Therefore, it is important that community members look after and support one another but also get more power as a community, which helps in achieving community set goals.

However, even though the community will have initiative and increased power themselves, there is an important ‘outside’ factor that trains locals and functions as a kind of supervisor (Macfarlane et al., 2000; Schuringa & Sibande, 2014). This is also obvious in the examples, where communities got support from the government and organizations. Support from these external parties can be in the shape of funding, providing a budget for the community program, or training locals to increase their capabilities and skills necessary for the program. It is important that there will be a balance between the community being able to develop their own programs with the guidance and management of external parties.

2.2.5 Government and community empowerment

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to what extent regulations allow communities to be independent and make their own decisions. Ahmad & Abu Talib (2013) explain in their article that decentralization initiatives are increasingly being used as an instrument in policies to support local development in developing countries. Especially by decentralizing decision-making, which helps with developing social capital and increasing community participation. This means that in order to support community-focused policies, responsibilities need to shift from government to local communities (Rolfe, 2015). Rolfe (2015) gives an example of this shift, explaining that the Scottish government developed their community empowerment agenda by changing legislation. Legislation has been changed in such a way, that communities now have “rights to request participation with public agencies, and increased rights to buy or control assets” (p. 2). A similar change happened in England, where communities were given rights to “undertake Neighbourhood Planning, instigate new house building, bid for local assets, and challenge and take over public services” (p. 2).

Ahmad & Abu Talib (2013) also emphasize that, besides power, the government also needs to support community capacity building and their access to resources, in order to make it work. Many initiatives for rural community development depend on ongoing support from the government, especially in developing countries.

2.2.6 Rural versus Urban

Where Ahmad & Abu Talib (2013) focus on the role of the government in rural areas, it is unclear if their results also account for urban areas is. Rural settings are different compared to urban settings; city life is very complex and more diverse compared to villages. This suggests that a (partly) different approach to community empowerment is needed and that different factors might play a role. Also in current literature regarding community empowerment, there seems to be a gap regarding its usefulness in urban settings. How community empowerment in Indonesian cities might work and what this could contribute to improving public health, is not clear.

2.2.7 Community empowerment in Indonesia

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though Indonesia has taken steps towards decentralization, local communities are not empowered. In order to realize effective flood governance there needs to be trust, something that can be achieved through community empowerment. When it comes to public health, Macfarlane et al. (2000) explain that even though the Indonesian government is providing essential health services for the poorer societies, these services will most likely not be sustained when the community itself hardly has anything to say in the process. By involving communities, there is a higher chance of success and sustaining services that have been realized.

That community empowerment can be the key to success in such matters shows in the results of Yayasan Cipta, an NGO in Indonesia who focuses on community empowerment in rural areas. They have been approaching different matters by using community empowerment; locals with certain authority or role were trained by this NGO and then carried it out in their own community. However, Yayasan’s main focus is on developing public health in rural, remote areas and not cities (Hartiningsih & Widiadana, 2014).

2.2.8 Recap of community empowerment and its importance for the research question

There is no format for community empowerment and how it should be implemented, but the literature directs towards several factors, which could play an important role. The fact that there needs to be a community in the first place and that they need to perceive it as a community themselves, is important. Not only the community itself needs to be taken into account, also external parties are mentioned in the literature. External parties, like the government, play an important role in making community empowerment work. Finally, factors like support from the community, education and freedom to make decisions also affect success. However, it is not clear if these factors are the same in both a rural and urban context, as the literature also suggests that there are differences between these two contexts. The exact role of these factors on community empowerment in Indonesia and differences between both contexts, are unclear. Exploring the use of community empowerment in public health programs in Indonesia and figuring out which factors affect it and what the differences between rural and urban are, will provide a way to discover how community empowerment could be used in cities to improve public health.

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3. Methodology

The purpose of this research is to explore how community empowerment can improve public health in cities of developing countries, with a focus on Indonesia. Research about community empowerment and what it could contribute to improving public health in urban settings is limited, not much research has been conducted yet. Besides that, several articles point towards a qualitative approach, like Thunhurst (2013) who states that qualitative techniques are recommended within an area of public health called community operational research, which has much in common with community empowerment. Community empowerment itself is a complex concept to study; its success depends on the context like the sense of community (Ahmad & Abu Talib, 2016), governmental institutions and the strategies of ordinary people in a community (van Voorst, 2016). It is something that cannot be practiced globally because local context matters (Islam, 2017). Based on the previous facts that community empowerment is a complex concept and its usefulness in public health in urban settings is yet to be discovered, this research will be qualitative. This qualitative research will result in a conceptual model that displays the results and describes the way community empowerment can improve public health and the factors that influence this relationship.

3.1 Research method

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people from outside the community who will support the process, assessing both and exploring different perspectives will provide a more complete picture.

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After carrying out the case study, the first round of 6 interviews and the second round of 5 interviews, all 11 conducted interviews will be transliterated and analysed by the use of ATLAS.ti. This tool will provide a systematic way to analyse all the data and secure consistency throughout the research.

3.2 Data limitations

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4. Results

All the 11 interviews, with employees of Yayasan and citizens of Jakarta, were transliterated and systematic analysed by the use of ATLAS.ti. Every sentence from the interview was given a code, which described the core message of what that interviewee said. Whenever, in the same interview or a different interview, something would be said that matches an existing code, that code would be re-used. If there were to be no code available yet to match the message of that sentence, a new one would be created. The whole process of open coding resulted in a total of 98 codes, which were checked and merged whenever possible, resulting in eventually 72 codes. These 72 codes were analysed again a second time by grouping them into overarching themes and this resulted in two main results, namely factors which impact community empowerment no matter the context and differences between the two contexts. The 72 open codes and matching sentences, which led to that code, can be found in the codebook in appendix chapter B. Most codes have been used more than once but in order to keep it clear, only one example of a part of an interview will be given.

In order to answer the research question as complete and clear as possible, the results are being discussed separately in two individual paragraphs. First the factors that have an impact on community empowerment in both rural and urban areas will be highlighted and secondly the differences between community empowerment in rural versus urban context will be highlighted.

4.1 Factors affecting community empowerment in both rural and urban context

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In every interview motivation and support emerged as an important part of community empowerment. It is not only crucial for the people who have an important role in the process but also for every single individual who will be involved. This ranges from ‘ordinary’ community members to community leaders and heads of involved governmental instances. Looking at that first group of people, if the ordinary community members do not see the purpose of the program and have no motivation to participate, it will be hard to achieve results for the other involved stakeholders. This is something which different interviewees described, for example in interview 3 where the interviewee described that they provide a training for villages to improve family planning. During this training not all the participants were interested and actively participating, the ones who were not participating did not do or achieve anything after the training. This can be explained by the fact that those participants did not see the purpose of family planning and did not support the program. Therefore, they did not have any motivation to participate, even though their leaders or other important people wanted them to. The same thing appeared to be the case in the interviews 7,8,9 and 11 with citizens of Jakarta. They responded negatively to questions if they would be open to do something their area leader (RT/RW) would suggest to improve welfare within their area. They would not do it because the lack of time or they would simply say it is not necessary and that they don’t care. This can also be explained by not understanding the purpose and need of the proposed action and therefore lack of motivation.

Not only among ‘ordinary’ members of the community this turned out to be an issue but also for leaders and other influential stakeholders. In interview 2 the interviewee explained that some leaders have their own priorities, which is not always what their community needs, and because of that they are not really supportive towards certain programs. It depends on the leader of the community, sometimes they have a passion for an issue and are motivated but sometimes they just don’t want to do it (interview 1).

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case they lose the support of those people/instances, it becomes more difficult and almost impossible to successfully continue the program.

So, in order to make a community program a success, there needs to be motivation and support at every level. In interview 4 the interviewee explained the reason why one community is more successful than another is because of the commitment that they show. This commitments comes from understanding the problem and needs of the community, which increases motivation. If they do not see the purpose and there is no support, they most likely will not do anything.

4.1.2 Education

A low level of motivation and support is mostly not because people are lazy or they do not care but it has to do with a lack knowledge about the program/issue. This could be addressed by educating the people involved with the community empowerment program, so that they will understand the purpose. By educating them they will understand the need, which will increase their motivation and thereby the chance of success of the program. Not only explaining the need of the program is beneficial, also education about developing a message to convince other people to support the program is important. Sometimes people involved with the program do not know how to approach other stakeholders. Education about advocacy can be very useful in order to gain support from all stakeholders (interview 1, 2 & 4).

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Not only in rural areas education is a crucial part, in the urban areas it seems just as important. In interviews 7, 8 and 9 the interviewees did not seem to be interested to participate in programs to improve welfare in their area. Their response to questions if they would participate in a cleaning program to deal with pollution, was that they did not care. Another interviewee did not understand the health issues, that for example pollution could cause, and threw his trash away wherever he wanted because everyone else did it as well (interview 10). Another problem was that when communities within cities wanted to implement and participate in programs, they did not know how to handle it (interview 1). All these problems were mainly caused by a lack of knowledge and education could be the key to make community empowerment programs work.

4.1.3 Control and monitoring by an external party

The above named component education is something that is most likely done by an external party. An external party could be a group, instance or individual who is not directly a member of the community where the program is being implemented. As explained in paragraph 2.2.3, external parties are an important part of the concept community empowerment and this also became clear during the interviews. External parties could fulfil several roles like educating, support, control and monitoring and is not only crucial in a rural context but also in an urban context.

From the interviews it became clear that education about how to spend the community fund or deal with different involved parties, was something that an external party carried out. Without education from an external party, it is difficult for a community to achieve goals if they do not have the knowledge. For example in interview 3 the interviewee explained that they (an external party) established a working group with people from a higher level like the district, who are involved with the program. This group then provided daily technical assistance to the communities (interview 3). So, external parties play an important role when it comes to educating communities which improves community empowerment programs.

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want. This would most likely not lead to effective expenditures and therefore, control is needed (interview 1). Thus, having an external party to who the community has to report to about their planning and plans for the funding, increases the chance of success.

4.1.3 Role of the government and instances

The government and instances play a crucial role in both rural and urban context by the organization of a country, its legal aspects and regulations. In the interviews 1, 2, 3, 4, 5 and 6, it became clear that a program to improve public health involves way more than only the community and its members. An interviewee explained that a deputy proposes to focus on remote areas and together with other instances, who are not a member of the affected community, they chose several districts and provinces who would be selected for community empowerment programs (interview 4). Getting selected means that these particular communities will get support of national, provincial and district instances with regard to funding and assistance. So, basically the government and instances decide which communities will receive support and help, which is crucial in community empowerment. Without some kind of financial and educative support, it is difficult for a community to achieve goals.

Not only support and funding from the government is something that influences community empowerment, also the organization of a country has a serious impact. Interviewees explained that when they were implementing programs in communities regarding family planning, it was very difficult to know who was responsible for what and connect all the stakeholders (interview 3 & 4). The government in Indonesia is decentralized and because of that, some districts have their own authority and village leaders have increased power to plan their own programs (interview 2 & 3). However, the people who ended up as leaders sometimes did not understand how to develop a program which would match their community’s needs (Interview 3). In addition to that, there were many different offices who were also involved on national and provincial level and the latter hired field officers for its sub-districts to support the programs. These different offices and officers started having discussions about trainings which should be included and because there were so many people and instances involved, this was not easy to solve (interview 3). Thus, in this case the organization of the country made it more complicated to implement community empowerment,

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something that could have an impact on community empowerment programs because it restricts the target group.

4.2 Differences between community empowerment in rural and urban context

The above named four factors: motivation, education, external party and government, have a crucial impact on community empowerment in Indonesia, no matter if it is in a rural or urban context. However, the data also directed to important differences between the both. A sufficient part of the open codes (20 of the 72) resulted in the overarching theme ‘difference urban & rural’. The network of open codes connected to this theme can be found in appendix A, figure 6. By exploring the open codes, 4 main differences could be discovered, which will be highlighted in the next 4 sub-paragraphs.

4.2.1 Comparing urban versus rural: Less autonomy

As described earlier, the government has a significant impact on community empowerment and there were some clear differences between a rural and urban context related to this factor. It seems that in cities the people who are responsible for a community (this leader is called RT/RW), which is a street or a block, have less autonomy compared to the responsible people in the villages (village leader). Due to decentralization in the Indonesian government, villages got more authority to run their own area. This means that a village leader has a say in developing a program for his or her village, which exists for example out of 10.000 people. In cities it is quite different, the RT/RW does not have much authority and decisions are made by the governor of the city (interview 2). This means that in a city like Jakarta, basically one person has the power to make decisions for 10 million people, resulting in decisions which do not (completely) match the needs of a certain community. When a village leader develops a plan, it will be more focussed on his/her community because he/she knows the people, area and what is going on. It is more difficult for a governor to make suitable decisions for one particular community within a city existing out of 10 million inhabitants.

4.2.2 Comparing urban versus rural: Different funding

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certain areas get a fund but this is meant for areas which exist out of multiple communities. Besides that, the budget that these areas in cities do get, cannot be spend on whatever they want because they do not have authority over how to spend the money (interview 4). An important part of community empowerment is having a fund; without any money it is almost impossible to achieve something. This is something that should be taken into account as a difference when implementing community empowerment in a city; the funding is very different in cities. The budget is way smaller and there is no freedom to spend it on community level.

4.2.3 Comparing urban versus rural: Differences in perception of what a community is

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important to explore different forms of communities and select the one that is most perceived as a community.

4.2.4 Comparing urban versus rural: Different social system

The social system is connected with the perception of the community. People in cities behave differently and interact differently compared to people who live in villages. As said in the previous paragraph, people in cities seem to be more individualistic than people who live in villages. Besides that, differences in income also seem to play a role. Whereas people with a bigger income live more isolated, people who are more ‘poor’ seem to behave more as a community (interview 7 & 9). Another difference is the way people in cities value their area leaders, they seem to have less authority than leaders in villages. In different interviews the interviewees said that they do not really care about their area leader (RT) and sometimes did not even exactly knew who he/she was. They said that if their RT proposes to do something as a community, they would not listen to him/her (interview 3, 7 & 9). Less authority could be partially caused by less autonomy a RT has compared to a village leader but it also seems to be connected with differences in social systems and the way people act within their community. In cities the RT just does not seem to have such an impact as the village leader has on a village. The reason why it is important to have someone in a community as a leader, who the members value, became clear in interview 4. The interviewee described that a key to successfulness of a program is a champion, someone who completely supports the program and has the ability to make a change in his/her community.

4.3 Conceptual model

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community empowerment program. Especially the latter is an important factor; without motivation of the community, the community empowerment program will most likely not succeed. In Indonesian cities this institutional context of community empowerment gets affected by four differences; less autonomy, different funding, perception of community and social systems (displayed in the lower rectangle in figure 1).

Figure 1

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5. Conclusion

The results of the research show that the relationship between community empowerment to improve public health in Indonesia, is influenced by 4 main factors: motivation, education, control & monitoring by external parties and the government. Motivation of the entire community (ordinary members, stakeholders, leaders and higher instances) is something that needs to be present. Without motivation, it is almost impossible to make a program a success. Education is an important factor, because it will help a community to deal with its lack of knowledge and missing abilities and skills. Education is mostly done by external parties, like for example an NGO, and creates awareness of needs, motivation, abilities and skills. External parties is a factor that is also named in literature about community empowerment and did indeed turned out to be important. They have another role besides education, which is control and monitoring of the whole process, to assure that everything is going according to plan and to provide support when needed. Finally, the government plays a crucial role by assigning funds, laws and regulations and the organization of its country. This is also something that emerged in literature about community empowerment. Besides these 4 factors there were 4 differences, which have a serious effect on community empowerment in cities in Indonesia. These differences are less autonomy, different funding, perception of community and social systems. In cities communities and community leaders have less autonomy compared to rural areas, which hinders community empowerment. There is also a different funding system for cities, which affects the budget and freedom to allocate it on community level. In cities the perception of a community is also different compared to rural areas. Communities based on neighbourhoods do not seem to perceive themselves as a community in the same way villages do. Perception of community is something that was also named in the literature and turned out to have an interesting effect on cities in particular. Finally, the social system in a city is also different compared to the rural areas, which effects the way a community functions and its successfulness.

Based on these factors and differences an answer to the research question “How does

community empowerment improves public health in cities in developing countries? Research in an Indonesian context” can be formed. First of all, the factors and differences affecting

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important start would be exploring which community in a city is being perceived as a community and what their social systems are like. This will make it easier to form an idea about who to target and what the community looks like. The community has to be the start of the program, so it is crucial to make sure what a community in a target area would look like. The way community empowerment is being implemented in villages, cannot be copied and used in a city. Different regulations with regard to autonomy and funding make that impossible. Therefore, these regulations need to be explored, so that they can be taken into account. After this has been explored, a program can be developed. This program should take the four factors into account; motivation, education, control and monitoring by external parties and government. Including these factors into a community empowerment program, will increase the chance of success. The concept community empowerment in public health programs in Indonesian cities, will most likely be more effective than a top-down approach. By assessing public health issues as a community, members will be more motivated and develop plans which match their community. The ‘strength’ of the community, its social capital and the power to help and motivate one another, will be put to use and contribute to achieve goals together.

5.1 Limitations

There were several limitations affecting this research, mainly regarding to the interviews. First of all, the language barrier limited responses and made communication more difficult. Partly because of that, the semi-structured guideline was difficult to follow because interviewees jumped from one point to another. Not only the language barrier was a limitation, also the fact that a non-Indonesian person approached them, might have affected their responses. Another limitation of this research is that the results are based on 11 interviews only. It is especially difficult to draw conclusions about Indonesian cities based on 5 inhabitants of Jakarta. Even though Jakarta is a good example of an Indonesian city, every city can have possible different factors or differences and it is therefore difficult to generalize based on these 5 inhabitants of Jakarta.

5.2 Implications & suggestions for further research

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Appendices

A. Network figures

Figure 2

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38 B. Codebook

Code Quote

Advocacy between different parts within community crucial

So that is why we also train, after we established the DWG so first province then district and then village and DWG, we train the village to also have a skill to be able to advocate the allocation fund to be able to be allocated in family planning activities

All parties need to be involved to make community empowerment work

Like I said before, for family planning programs to be successful you cannot depend only on the family planning office but at the same time they have a different perspective on how people, even in government, see family planning because they see it only as contraception

All stakeholders need to see purpose of community empowerment

and then at first we will meet the mayor or district head. So really the key is that we are not bringing the program or project to the village but we actually come to the government who’s district or province needs support from us. So actually we are here and they need support in a particular area.

All stakeholders of community empowerment need to be involved

That is why the district working group is important because we will encourage them to be led by the head of district. So the head of district will invite them to come together and talk about family planning, so the main focus of advocacy is district is the head of district or all the leaders in district level who have the higher status than the family planning office

Assumptions and resistance within community effect community empowerment

I mean how to advocate the secretary of the district who is quite resistant against family planning or how to encourage the head of district to issue a letter to support family planning

At every level involved parties need to be empowered

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mobilisation and it is a part of strategic communication so the main effort is that we need to empower, we need to empower the government, with Kampung KB we need to empower the community. So, at every level we need to empower every individual

Attitude of role models within community have impact on success

A champion is a family planning advocate, like a role model so who can lead the movement but also has a concern for family planning

Behaviour change crucial for community empowerment

Besides family planning we also did behaviour change and communication on water and sanitation but that is finished since 2014. We promote the five pillars of the total sanitation in the community: washing hands with soap, how to manage household waste so this is a kind of behaviour change communication and advocacy Collaboration between parties is

key

So that is what we are doing, we try to make them collaborate and we encourage them to establish a DWG, a district working group

Combination of outside people and inside

Actually head of the village already exists so we establish empowerment for the community to set up the task force and with the head of the village. Then the custom people, the traditional people in Indonesia and the import people of the village become the task force and they decide to use the money and then discuss with the head of villages because it is not only the authority of the head of villages but they also have to consult the district bupati or mayor to get an agree Commitment of community is

crucial

From our experience it is the commitment that they have shown, more than anything.

Community develops own plan with help external parties

so what we are doing after they established a DWG, we train them so they can establish a work plan or program

Community doesnt have necessary data

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That is what happens every year. So for example in terms of family planning they don’t identify their needs for contraceptives in a certain area, they just rely on the previous planning

Community empowerment depends on choices authorities

The deputy proposes that we should focus on the province where they need it most but also in remote areas so that is why we came up with 4 districts in 3 provinces and the first step of the implementation is meeting with BKKBN at the provincial level and together with the provincial BKKBN we selected the district based on the data and information they had. Community has high autonomy

(village)

So actually our support is not on daily basis on the village level so here is the thing, at the district level we have this working group, the district working group, so this group is the one who provides daily technical assistance to the village.

Community is not always village So, Karawang tried to find a way to connect with the immigrants and that is why they involved the companies because through companies, actually these are big factories, they usually have their own clinics and their own service providers. That is why Karawang government should include them also in the program to be able to reach the immigrant workers Community lacks important skills You can see that sometimes it is too dirty and they have

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Community needs to be aware of needs/problems

The key for the community empowerment is to involve them because otherwise it is only the project and they do understand that it is beneficial for them.

Community needs to be involved So we ask the people from the red area what the solution is so they are involved.

Community needs to be motivated From our experience it is the commitment that they have shown, more than anything.

Community uses own data to develop plan

Actually we identify problems and we use data and we can see for example the potentials of a certain area and what we should develop

Community uses tools to identify potential

So those tools actually help the community to identify their potential. So for the tools for example we use their own data, evidence based, they have their own data and based on that we develop their own strategies. These tools make it great, they can be adapted on every issue

Complicated organization of country

The family planning office they have on national level, province and district level and what we do with our programs is that we are working in sub-national level, like province and district

Connect stakeholders and parties of community empowerment program

We are trying to connect their needs to the district level. At the district level all the agricultural, sanitation offices have their own program and then they try to synchronize so they can decide that for example this village needs seeds or a sanitation system, they allocate the programs to that village.

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Decentralization in country makes community empowerment more complicated

So because this decentralization era the mayor has their own decision regarding development agendas including family planning and this is why advocacy is important because when the national BKKBN said that the mayors have to prioritise family planning, it all depends on the mayor whether they want to or not. So that is why BKKBN provided technical assistance and instruct to do anything but the coordination is not always on place and it depends on the area.

Difference between village and urban funding

But the Kelurahan they don’t have the budget from the national they only have the budget from the district. Different authorities are involved

and influence success

then they submit the result of this discussion to sub-district and then they do it to sub-district and they will approve the proposal. Then from the district they will submit it to the national government and then they will transfer the fund.

Different feel in urban community compared to village

Uhm yeah I am close because it is a very small area. In my area it is only one road, so it is 500 meters and 1 RT. Every community member who is in that area RT should know.

Different level of autonomy between villages and cities

Yes, and they don’t have the authority to decide what kind of allocation they want to choose. So yeah this is very difficult but for the planning process and budgeting process,

Different participation in community due to age (urban)

Right now I feel like more individual but the older the more activity, when you are not busy and working all the time.

Different social structure and organization in city

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Education about how to use funds we empower them on how to utilize the money and how to advocate to the district head about the money for the family planning.

Education also crucial in urban area But for the community empowerment in the cities and the resilience it needs education about how to prepare Education and tools improve

community empowerment

we provide the capacity to do this working group and we empower them by using netmap, this is the how to map out the stakeholders who are related to the family planning and also smart; how to make the advocacy work plan.

Education is crucial also in urban communities

But again education is very important so they know how everything works.

Education is crucial in community empowerment

Actually how the money can be used for family planning because if not the village will use the money only for the infrastructure instead of family planning. Education to improve public health Besides family planning we also did behaviour change

and communication on water and sanitation but that is finished since 2014. We promote the five pillars of the total sanitation in the community: washing hands with soap, how to manage household waste so this is a kind of behaviour change communication and advocacy Education, support and

understanding of higher people in community crucial

Well we do show them some kind of simulation on how we can make a work plan based on your needs and like on the training on the village level we ask them to bring village maps and data about the village so they can identify which problem their village has and what kind of program they need and where you ask for help, in district level or province level. So we help them to identify their needs and how they can achieve that step by step.

Establish task force within community for support and control

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the custom people, the traditional people in Indonesia and the import people of the village become the task force and they decide to use the money and then discuss with the head of villages because it is not only the authority of the head of villages but they also have to consult the district bupati or mayor to get an agree Establish working group within

community with help of external parties

We have people at the district level and they accompany the people at the district level because at the district we have also set up the district working group.

External parties cannot tell community what to do

So the key is that we cannot just come to the district and then tell them no, we have to act and work together with the tools and the technical assistance.

External parties support community to deal with issues

Yeah, well they just have to revise it actually because the training that we give is already very throughout, like very complete. So on village level they usually revise some points because we give them, the way they do all the work and the steps it already fulfils everything they need in a way.

External party monitors progress within community

So, we do not provide our beneficiaries with money but we build their capacity including to plan, implement and also monitoring and evaluating the effort.

Funding for villages to improve public health

you know in Indonesia there is a regulation from the president that every village/district have money around 1 billion us dollar for the empowerment of family planning, water and sanitation and infrastructure. So we advocate the district and the head affiliates to utilize the money for the family planning. Funding plays crucial part No but actually because not much money can be given

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Government plays crucial role When we pick province or district for our intervention, we consult the national level about which province needs help according to them so they can be for example more effective

Governmental regulations and law influence community empowerment

Oh the district office? So they already have some programs involving family planning stuff but the reason why it is not very effective, in my opinion, has to do that they try to do everything alone and don’t involve others and they have to do the work alone. High motivation on village level But so far, in terms of participation, I think in village

level is much better than what we had in district level. So in district level it is difficult for the head of the office to come because it is the same level as family planning office and they just send a staff member. Increase capacity of community

itself

and we connect the capacity building for the village members to what is already there and we use those 2 tools to increase their capacity as a kampung KB advocate

Initiative has to come from community

The effort is from themselves and we can be supportive to that.

Less control and power of authorties/social hierarchy in city

No I don’t think so you know some of the people they do not care they just do what they want. They are to the RT or RW like they can clean themselves.

Less feeling of community in cities Yes we are close so when we see each other outside or on the street we talk and I know them but we don’t do many things together. For example in the evening I am in the house and not really outside so then we don’t see each other

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Less vertical hierarchy in city Yes well in my block his job is only RT because when you go to RT to make a new ID or something else you are going to give money to him and the RT gets paid by the government yes the government pays for the RT.

Level of outside control to make community empowerment work

Because otherwise they can use the money for whatever they want and it is also the interest of other parties.

Lower level of autonomy in city He is the governor of the whole of Jakarta and he can choose the mayors for the districts. He will discuss it with others but people in Jakarta only elect the governor and then he will decide who will be mayor. So they don’t have much authority, they have to report to the governor.

Many differences within one city Yes I think that this area which is more poor they still want to work so if the RT will tell them to clean up the area they will do it but in a more rich area like Kemang no with houses more apart people don’t know each other, they don’t know the neighbour.

Method to create awareness in community

So there is this thing where people have to evaluate and go around their area and draw a map which is a high risk area and which one is safe.

More diversity in city compared to village

Yeah maybe because the people who have less money in a poor area they stay outside and they meet and talk more and in the night they will come from work or go to work and talk outside the house with each other. If people live in a big house with a fence then they will stay there, they will come back from work and just stay at home.

Motivation of key persons in community is crucial

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No clear leader in urban communities

Uhm there are some documents that should be signed by these two so that is why the community, like us, should know who their RT and RW is. So we should call them when we have any problems.

No force from outside it has to come from community itself

We encourage people like the RW to do that, so tell him that how about this year we do a training on hygiene twice a year in this area and then they will think about how they are going to do it by themselves so we assist them.

Not many activities in community (urban)

Yeah right now mostly all people in my area are elder and the younger ones have gone somewhere else so there is not much activity.

Planning is crucial So this Lantung village their Kampung KB is successful because they have, the thing is that one of the problems that Indonesia faces is that we don’t document and the village does not have the capacity to systematic plan

Problems in urban communities not always clear

Sometimes we also assume that city people don’t have a problem, that it is fine for them but they do have problems like drugs or gender based violence because of the economic status.

Results community empowerment depend on view of important people within community

But we really try to sustain the program by the commitment of the district leader or the village leaders because they have 5 years of governance so hopefully they will strengthen it enough to improve everything. Services offered by government

influence community empowerment

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Shape of community empowerment depends on involved stakeholders

she cannot get anything from the Jakarta government because she is not a citizen. That is why, the idea of family planning process is that it is for all so Karawang government would like to provide family planning services to all the communities and all the people in Karawang, not only to the locals, so whether they are an immigrant or not.

Social system influences community empowerment

In the community where they are more bonded they usually have programs, you know like simple cleaning the environment together or on independence day they have competitions. They are mostly organized by RT or RW, they have like a regular meeting every month. Even the wives, the women, they have a routine meeting of RT and in this regular meetings they work on government problems, like primary health care programs or if they want contraception stuff on RW level.

Unclear who has authority in cities Well RT is for small block of houses and bigger one is RW, I think in my area 5 RT is one RW. What is the RT? I don’t really know actually what the meaning of it is, we just have it and it is a way to organize but I don’t really understand.

Urban community more individualistic

Community empowerment as a way of improving public health in vulnerable and growing urban areas in developing countries; Empirical results from Indonesia